The Women's Center – Sign up for counseling

1.4

Date intake completed:

Date no case made:

Client #:

New Client Intake

We offer both sliding-fee and insurance-based counseling services. If interested in using insurance, we accept the following: Medicare, Blue Care Network of Michigan, Blue Cross Blue Shield, Blue Cross Complete, and Meridian. We also accept out-of-pocket, private pay.

How did you hear about us (referral source)?

Are you a returning client?*

Yes
No

Contact Information

Legal name

First Last

Chosen/preferred name

Pronouns

Gender

Sex (legal status on ID)*

Age*

Birthdate*

MM

DD

YYYY

Race/ethnicity

Address*

Street Address Address Line 2 City ZIP Code

County

Phone Number (first choice)*

Secondary Phone Number

Email

Enter Email Confirm Email

Emergency Contact

Emergency contact will only be reached in the circumstance: we are unable to reach you by any of your provided means, we are concerned for your safety, or you experience a medical emergency while at our facility.

Emergency contact name*

Relationship to emergency contact*

Emergency Contact's Phone*

Insurance Information

Do you have health insurance?*

Yes
No

Are you interested in using health insurance to cover therapy?*

Yes
No

Primary Insurance

Insured's Legal Name

First Last

Relationship to Insured

Insured's Birthdate

Primary Insurance Company Name

Customer Service Phone Number

Insured ID #

Group #

Secondary Insurance (if applicable)

Do you have secondary insurance you would like to use?

yes
no

Insured's Legal Name

First Last

Relationship to Insured

Insured's Birthdate

Secondary Insurance Company Name

Customer Service Phone Number

Insured ID #

Group #

Insurance Verification

Insurance Rep/Portal

Date & Time:

Therapist name:

Therapist NPI #:

Provider(s) In or Out of network?

Effective date:

Pre-authorization required? Y N

Authorized # of visits:

Starts:

Expires:

Authorization #:

Sliding-Scale Information

If you do NOT want to use insurance and would rather pay a sliding-scale fee please fill out the following two questions.

What is your estimated monthly household income?

How many people live in your household?

Other Information

Available days/times for appointment:

Best times to contact you:

Is it safe to leave a voice mail message?*

Yes
No

If not, do you feel comfortable sharing why?

For the purpose of sending forms online: Do you have access to a computer and/or the Internet?

Yes
No

Are you willing and/or comfortable with seeing a male therapist?

ok
not ok
maybe

Are you interested in short-term therapy (10 or less sessions)?

ok
not ok
maybe

Do you identify as having a disability?

Yes
No

If yes, do you feel comfortable sharing?

Do you need any accommodations related to language, accessibility, allergies, etc.?

Yes
No

If so, what accommodations?

If comfortable, would you share why you are interested in counseling at this time?

Are you currently seeking therapy for any of the following reasons (check all that apply):

court mandate
legal issues (e.g. custody, child support, etc.)
to apply for benefits
letter of recomendation

If comfortable, can you tell us what medications you are currently taking?

Have you ever received mental health services before?

Yes
No

Have you been hospitalized for emotional or psychological issues?

Yes
No

In the past year, have you at any time seriously considered suicide?

Yes
No

Do you need a referral for any of the following resources?

Please check all that apply.

Health Insurance
Dental Coverage
Food Resources
Primary Care Doctor
Housing Assistance
Crisis Line Information

CAPTCHA

Co-pay (flat fee)

Primary

In-Network
Out-Network

Secondary

In-Network
Out-Network

Primary

Secondary

Yearly deductible

In-Network	Out-Network

In-Network	Out-Network

Sign up for counseling

New Client Intake

Contact Information

Emergency Contact

Insurance Information

Primary Insurance

Secondary Insurance (if applicable)

Insurance Verification

Sliding-Scale Information

Other Information

Co-pay (flat fee)

Primary

Secondary

Yearly deductible

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