Name *

First Name

Last Name

Phone *

(###)

###

####

How do you prefer to be contacted?

Email

Phone

Are you located in Michigan? *

Yes

No

Preferred Counselor *

Amanda Waldron, LMSW

Kristen Bylsma, LMSW

No preference

If you are hoping to use your insurance, what insurance carrier do you have? *

Aetna/Cofinity

Blue Cross Blue Shield

Blue Care Network

Cigna

Medicaid (McLaren, Meridian, Priority Health, Blue Care Complete)

Priority Health

United Health

Not Listed/Out of Network - Cost will be $130/session.

If you could not select insurance above or if you do not want to use your insurance benefits, the cost per session will be $130 and can be paid by HSA/FSA, check, cash, or credit card. Are you able to invest $130 per session at this time?

Yes, I can pay the full fee.

No, I would be unable to pay the full fee.

Are you looking for a specific type to therapy? *

In-Person

Teletherapy

Trauma Therapy/Brainspotting

Cognitive Behavioral Therapy

Acceptance and Commitment Therapy

Exposure and Response Prevention Therapy

Other

Are you concerned about your eating habits? Is this something you would like to address in therapy? *

Yes

No

Are you concerned about your alcohol or drug use? *

Yes

No

Are you concerned with any repetitive behavior or thinking that you think could be obsessive-compulsive disorder? *

Yes

No

What Age Range/Stage of Life Best Describes You?

12-17

18-29

30-39

40-49

50-59

60+

Time

Do you have a time of day that you prefer to meet? Check all that apply.

Morning

Lunchtime

Afternoon

Evening - not available at this time