Intake Form

1
Who is this appointment request for?* This field is required.You can request this appointment for yourself, on behalf of someone else, or for both you and your partner. Please choose below.
Me
My Partner and Me
Someone Else
2
Your Name* This field is required.
First Name
Last Name
3
Your Email* This field is required.
example@example.com
4
Your Phone Number* This field is required.
Please enter a valid phone number.
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Insurance* This field is required.Before selecting BCBS please confirm it is not a Blue Cross Complete, Blue Cross Medicare, or Blue Care Network plan. Only select providers are in network with BCN and we are out of network with BCC and Blue Cross Medicare.
Blue Cross Blue Shield (BCBS)
Blue Care Network (BCN)
Priority Health
Aetna
Cigna
Out of Pocket
Physicians Health Plan (PHP)
7
Out of Pocket Rate Reminder* This field is required.
8
Partner's Name* This field is required.
First Name
Last Name
9
Partner's Email* This field is required.
example@example.com
10
Partner's Phone Number* This field is required.
Please enter a valid phone number.
11
Partner's Date of Birth* This field is required.
Date
Year
Month
Day
12
Is the potential client a minor?* This field is required.
Yes
No
13
Potential Client's Name* This field is required.
First Name
Last Name
14
Potential Client's Email
example@example.com
15
Potential Client's Phone Number
Please enter a valid phone number.
16
Potential Client's Date of Birth* This field is required.
Date
Year
Month
Day
17
What services is the potential client interested in?* This field is required.
Individual Counseling
Couples Counseling
Child/Adolescent Counseling
Group Counseling
EMDR
18
What are the main concerns?* This field is required.Please select all applicable concerns.
ADHD
Addiction / Substance Use
Adoption
Anxiety
Asperger's Syndrome
Assessment/Psychological Testing
Behavioral Issues
Depression
Divorce
Family Conflict
Grief
Impulse Control Issues
LGBTQ+ Issues
Marriage Issues
Men's Issues
Mood Disorders
Obsessive-Compulsive (OCD)
Parenting
Peer Relationships
PMDD
Pregnancy, Prenatal, Postpartum
Relationship Issues
School Issues
Self-Esteem
Spirituality
Stress
Trauma
Women's Issues
Other
19
Is the potential client open to online counseling?* This field is required.
YESNO
20
Is the potential client open to being seen at our Chelsea location?* This field is required.
YESNO
21
Is the potential client open to being seen at our Ann Arbor location?* This field is required.
YESNO
22
Please select your preferred location.* This field is required.Please indicate all possibilities. The wait time is longer for our Chelsea location.
I am flexible, first available.
Chelsea
Ann Arbor
Virtual
23
What is the potential client's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
Morning (8am - 12pm)
Afternoon (12pm-3pm)
Evening (3pm or later)
24
What are the goals/concerns to work on in counseling?* This field is required.Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. Also please note if you have any specific limitations to your availability. This could affect wait time.
Huge
Large
Normal
Small
Ok
Ok
25
How did you hear about us?
Should be Empty: