Med Intake

1
Who is this appointment for?* This field is required.
Me
My Child
A member of my family
2
Are you currently receiving care at Mala?* This field is required.
YESNO
3
Has anyone in the member of your household ever recieved care at Mala?* This field is required.
YESNO
4
Your Name (If you are a parent, put your name here)* This field is required.
First Name
Last Name
5
Your email* This field is required.
example@example.com
6
Your Phone Number* This field is required.
Please enter a valid phone number.
7
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Child's Name if Under 18This question does not apply if you are an adult seeking services for yourself.
First Name
Last Name
9
Client's Date of Birth* This field is required.This is the date of birth of the person you are seeking care for.
Date
Year
Month
Day
10
Which location are you inquiring about?* This field is required.
Ann Arbor
Farmington Hills
Plymouth
Virtual
Any
11
Is your child in a divorced or separated household?* This field is required.If filling this form out for an adult, please select "no"
YESNO
12
Do both parents have legal custody?* This field is required.If yes both contacts need to be the parents. If filling this form out for an adult, please select "no"
YESNO
13
Contact #2 Name* This field is required.*If this is a divorced or separated household this MUST be the other legal guardian for legal reasons.
First Name
Last Name
14
Contact #2 Email* This field is required.*If this is a divorced or separated household this MUST be the other legal guardian for legal reasons.
example@example.com
15
Contact #2 Phone Number* This field is required.*If this is a divorced or separated household this MUST be the other legal guardian for legal reasons.
Please enter a valid phone number.
16
Contact #2's Relationship to Client* This field is required.
17
Insurance* This field is required.We are only in network with Blue Cross Blue Shield (BCBS), Blue Care Network (BCN) and Aetna for medication management. We provide out of pocket services to clients who have other insurance plans. Please look at our out of pocket costs on our website. We will provide private pay clients a superbill so they can seek reimbursement from their insurance. * We are NOT in network with Blue Cross Complete*
Blue Cross Blue Shield (BCBS)
Blue Care Network (BCN)
Out of Pocket/ Private Pay
Aetna
18
Upload photos of insurance card (front and back) so we can verify your benefits.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Primary Insured's Date of Birth* This field is required.
Date
Year
Month
Day
20
What is your reason for seeking Medication Management? * This field is required.
21
Do you have a clinician preference?
22
How did you hear about us/who referred you to us?* This field is required.
23
Would you like to be added to our newsletter? * This field is required.
YESNO
24
By submitting this form, you will be added to our medication management intake list. We will contact you within 24-48 hours via phone call and email. For questions, email Senna Flora at meds@malafamily.org.* This field is required.
I have read and understand this.
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