Appointment Request
After you fill out this request request, we will contact you to go over details and availability before your appointment is scheduled. If you have any questions please contact us at Contact us at (734) 719-0418 or info@deltalifecounseling.org
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Name *
Birthday *
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DD
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E-mail *
Phone *
Reason you're seeking counseling services. *
Can we text you? *
Required
Preferred contact method *
Required
Are you using insurance? If so please tell us the type and the group or ID number. *
Are you willing to meet virtually (telehealth)? *
Required
What days and times are you seeking services? *
By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "I agree" you agree to hold Delta Life Counseling harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. *
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