New Patient Inquiry

1

Are you looking for counseling for yourself?

YESNO

2

What is your name?* This field is required.

First Name

Last Name

3

What is your Date of Birth?* This field is required.

Date

4

Clerical Staff Notes

5

If for someone else, please list potential patient's name and date of birth:

First and Last Name

Date of Birth

6

What is your email?* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification.

••••

7

What is your Phone Number?* This field is required.

Area Code

Phone Number

8

What Is Your Address?* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

9

Please describe in a few words the reason you are seeking counseling.* This field is required.

10

Would you like to use your insurance for services, if possible?* This field is required.*It's important to note that most insurance companies do not cover marital therapy. Please check with office staff for details.

YESNO

11

What type of insurance do you have?

12

Is the patient the primary subscriber for the insurance?

YESNO

13

Please List The First and Last Name of the Subscriber and their Date of Birth

First and Last Name

Date of Birth

14

If you would like us to verify your insurance benefits, please upload an image of your insurance card, here. Please note this is NOT a guarantee of coverage. We verify insurance as a courtesy to our patients.

Drag and drop files here

Select files to upload

15

Are you interested in tele-therapy? (It's like Skype or Facetime, but HIPAA compliant). Due to COVID-19 crisis, the majority of our sessions are being held via our tele-health platform - TherapyPortal. Availability for in-person appointments is extremely limited at this time.

YESNO

16

What days and times are you available for appointments?Day of the week, time of day, ect

Enter any Days and Times that you are available

17

Is this request for therapy court-ordered?

YESNO

18

Do you have a certain therapist at Charis you would like to see if possible?Please select all therapists that you are willing to see (you can read each therapist's profile under the "Meet the Team" tab.

19

Is there anything else that you think we should know?

20

Thank you for your interest in Charis Counseling Services of Northeast Michigan, PLLC. We will get back with you just as soon as we can. As we currently have a waiting list, we will not contact you unless we need more information or have a potential opening. If this is a behavioral health emergency, please call 911 or go to your nearest emergency room for immediate assistance. For urgent matters, you may contact Northeast Michigan Community Mental Health at (989) 356-2161.

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.