Request an Appointment
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Patient Name *
First and Last 
(Full Legal Name) 
Patient Date of Birth *
MM
/
DD
/
YYYY
Email Address *
Phone Number *
Gender *
Please provide a brief summary of reason for seeking counseling.
 *
Who is your Primary Insurance Provider?
 *
Insurance Member ID:
(Found on Insurance Card) *
Insurance Group Policy Number: 
(Found on Insurance Card)
 *
Do you have secondary insurance? If so, who is your secondary insurance provider? *
Please select which clinicians you are open to being scheduled with. 
(All of our clinicians offer virtual sessions)
 *
Required
We offer in-person session in Wayland and Battle Creek, as well as virtual sessions. What are you open to? 
(Select all)
 *
Required
When are you available? *select all that apply *
Required
If you are submitting a request for someone other than yourself please provide your name and relationship to the patient.
If this is a request for a child, is there any type of shared legal custody? (If there is shared legal custody we will need to obtain consent for services from all parties) 
Clear selection
Do you have any accessibly needs we can accommodate for? *
How did you hear about us? *
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