Client's First Name *
Client's Last Name *
Parent First Name (if patient under 18)
Client's Email (or parent email if minor patient) *
Phone Number *
When is the best time to reach you by phone?
Morning
Afternoon
Which counseling services are you interested in? *
Young Child Counseling (Under 6)
Child Counseling (7-12)
Teen Counseling (13-17)
Adult Counseling (18+)
Couples Counseling
Family Counseling
ADHD Treatment
Medication Management
If on a desktop, press CTL or CMD to select multiple options
Please Select Your Payment Method *
Please select one
Aetna - In Network
Blue Cross Blue Shield of MI - In Network
Blue Cross Blue Shield - Out of State
Blue Cross Complete - Do Not Participate
Blue Care Network - In Network
FEP Blue Cross Blue Shield - In Network
Cigna - Out of Network
Medicaid - Do Not Participate
Medicare - In Network
Meridian - Do Not Participate
Meritain - In Network
Messa - In Network
Molina - Do Not Participate
PHP - In Network
Priority Health - In Network
United Healthcare - Out of Network
VA Community Care - Out of Network
Other
Private Pay
Additional Details (Please specify any clinician preferences you have like specialty, BIPOC, LGBTQ+, treatment goals, or other relevant information)
Submit