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Name *

First Name

Last Name

If inquiring for your child, what is the current custody status?

Leave blank if this does not apply.

Parents are married

Shared legal/medical custody

Sole legal/medical custody

Pronouns

What are your pronouns?

She/Her

He/Him

They/Them

Phone

(###)

###

####

Are you comfortable seeing one of our graduate-level counseling interns?

Sessions with interns are a flat rate of $25/session.

Yes

No

Do you prefer in-person or telehealth sessions?

In-Person Only

Telehealth Only

No preference

Insurance Provider

We are currently in-network with BCBS, BCN, PHP, Aetna, and McLaren. *Not all clinicians are in-network with every insurance - please make sure you select your specific insurance plan as that is how we'll help match you with the very best fit counselor!

Blue Cross Blue Shield (BCBS)

Blue Care Network (BCN)

Physicians Health Plan (PHP)

Sparrow Physicians Health Network (SPHN)

Aetna

McLaren

Other