Online Registration Form**

Please complete the form below.

Once your information is received, we will call you to schedule an appointment.

We currently have a waitlist but will do our best to schedule you as soon as possible. In general, the wait time for telehealth appointments is shorter than in person appointments.

**(Completing the form does not guarantee services.)

Client First Name(Required)

Client Last Name(Required)

Parent/Guardian (If applicable)

Birthday(Required)

Phone(Required)

Country/Region(Required)

Address(Required)

City(Required)

Zip / Postal code(Required)

Email(Required)

How would you like to receive services? (Required)

I am open to In Person or Telehealth

In Person only

Telehealth Only

Briefly explain your reason for seeking services. (Required)

Choose all that apply(Required)

I am currently being seen by a mental health professional.

I have been in therapy in the past.

I have been in substance abuse treatment in the past.

The therapy that I am requesting has been mandated or required.

None of the above.

Insurance(Required)

I have Medicare.

I have UPHP and/or Michigan Medicaid.

I have commercial insurance.

I don't have insurance.

I don't know what insurance I have or if I have insurance.

We occasionally have interns who offer short-term therapy at no cost. Would you be interested in working with an intern?

Is there anything else you would like to share to help us find the best therapist for you?

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