Are you inquiring about services for yourself or someone else?*

SelfSomeone else

If someone else, please share your information:

Your name

Your email

Your relationship to the client

Prospective Client Information

Affirmed Name (we will use this name when we contact you)

Full legal name* (this helps us set up your account properly)

Pronouns*

Email*

Phone number*

Age*

Ethnicity (optional)

Which type of therapy are you requesting? (Select all that apply)*

Individual therapyRelationship/family therapy (more than one client)Therapy for child or teen under 18 years old

What is your preference for a therapist? (Select all that apply)

Note: Available therapists of color currently have virtual appointments available only. Available LGBTQIA2S+ therapists have both in-person and virtual appointments.

I prefer a therapist of colorI only want to see a therapist of colorI prefer an LGBTQIA2S+ identified therapistI only want to see an LGBTQIA2S+ identified therapistIf my preferences are not available, I can work with a therapist who is an ally

What is your preference for appointments? (Select all that apply)*

Telehealth onlyIn person onlyTelehealth or in person, whichever will get me scheduled the soonest

Who is your preferred therapist, if any?

---No preferenceAmandaAngelinaCassieClaireDreaErinFrankFrankieJessJesperJoelJuliannaKatieLexieMirandaMyaSydney - InternParker

Are you open to being seen by a master's level intern?*

YesNo

Please briefly tell us what brings you to therapy.*

What is your availability for appointments?*

How will therapy costs be covered?*

---Self-pay: Therapy with an intern for lowest rates ($0-$40 per session)InsuranceSelf-Paying: full rate — $225 per appointmentSelf-Pay: Apply for reduced rates ($80-$225 per session)Client is LGBTQ+, BIPOC 13–25 years old. I would like to apply for grant help.

If using insurance, please complete this section.

Primary insurance plan

---Aetna CommercialBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMeridian CommercialMeridian MedicaidMolina CommercialPriority Health CommercialPriority Health MedicaidUpper Peninsula Health PlanInsurance not listed, can I use out-of-network benefits?

Secondary insurance (if applicable)

---No secondary insuranceAetna CommercialAetna MedicaidBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMolina CommercialPriority Health CommercialPriority Health MedicaidUnited CommercialUnited MedicaidUpper Peninsula Health PlanSecondary insurance not listed

Please upload a picture of the front and back of your insurance cards.

Front of primary insurance card

Back of primary insurance card

Insurance subscriber full name

Insurance subscriber birthdate

Please upload a picture of the front of your identification or driver's license.

You will receive an email response the same day or next business day. We’ll send your estimated cost per appointment and your first therapy appointment date/time. If that date/time does not work, you can reply and let us know.

We will also send you a link to complete forms. Forms MUST be completed before your first therapy appointment.

Would you like a free virtual appointment to complete forms with our intake specialist, or will you complete the forms on your own?*

I would like an appointment to complete formsI will complete forms on my own

Anything else you’d like us to know?

If the prospective client is a minor, select all which apply:

Parents are marriedOne parent has sole custodyParents share joint custodyThere is not a legal custody agreement

If both parents have legal rights, please list the other parent’s information:

Legal name

Email address

Phone number

If you are inquiring about relationship/family therapy, please provide information for all other participants:

Affirmed name(s)

Legal name(s)

Email address(es)

Phone number(s)

We must be able to email you to complete the intake process. Please check your email daily.

Which other types of communication do you consent to?

TextPhone call

We cannot legally provide therapy across state lines. Do you understand you must physically be in Michigan during telehealth appointments?

YesNo

Terms of Use

Yes, I want to submit this form. Those who submit any forms on the Wild Ferns Website are added to our email newsletter and will receive 1-2 emails every 1-2 months. Newsletter recipients can easily unsubscribe. Email addresses are not shared with other newsletter recipients. Furthermore, by submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Wild Ferns Wellness Center, LLC and Transformative Therapy & Consultation Services, LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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