Are you inquiring about services for yourself or someone else? selfSomeone else
If someone else what is your:
name? email address? relationship to client? Please answer the following questions about the person who the client will be. Affirmed Name (We will use this name when we contact you-skip if affirmed name is same as legal name) Full legal Name (if you start therapy with us, this helps us set up your account properly.) Pronouns Email Phone number Age Ethnicity (optional): How will therapy costs be covered? InsuranceSelf-Paying WITHOUT insurance: full rate-$225 per appointmentSelf-Paying WITHOUT insurance: I would like to apply for reduced rates If using insurance, which primary health insurance plan do you have? CLICK HERE TO SELECTAetna CommercialAetna MedicaidBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMolina CommercialPhysicians Health PlanPriority Health CommercialPriority Health MedicaidUnited CommercialUnited MedicaidUpper Peninsula Health PlanInsurance not listed, can I use our of network benefits? If applicable, which secondary health insurance plan do you have? CLICK HERE TO SELECTNo secondary insuranceAetna CommercialAetna MedicaidBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMolina CommercialPhysicians Health PlanPriority Health CommercialPriority Health MedicaidUnited CommercialUnited MedicaidUpper Peninsula Health PlanSecondary insurance not listed
Please answer the following questions about the person who the client will be.
Affirmed Name (We will use this name when we contact you-skip if affirmed name is same as legal name)
Full legal Name (if you start therapy with us, this helps us set up your account properly.)
Pronouns
Email
Phone number
Age
Ethnicity (optional):
How will therapy costs be covered?
InsuranceSelf-Paying WITHOUT insurance: full rate-$225 per appointmentSelf-Paying WITHOUT insurance: I would like to apply for reduced rates
If using insurance, which primary health insurance plan do you have? CLICK HERE TO SELECTAetna CommercialAetna MedicaidBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMolina CommercialPhysicians Health PlanPriority Health CommercialPriority Health MedicaidUnited CommercialUnited MedicaidUpper Peninsula Health PlanInsurance not listed, can I use our of network benefits?
If applicable, which secondary health insurance plan do you have? CLICK HERE TO SELECTNo secondary insuranceAetna CommercialAetna MedicaidBlue Cross Complete MedicaidBlue Care NetworkBlue Cross Blue ShieldHuron Band of the Potawatomi Health InsuranceMclaren CommercialMclaren MedicaidMolina CommercialPhysicians Health PlanPriority 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.
What is the insurance subscribers full name?
What is the insurance subscribers birthdate?
Please upload a picture of the front of your identification or driver's license.
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)? : 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, which ever will get me scheduled the soonest
Who is your preferred therapist, if any? CLICK HERE TO SELECTNo preferenceCassieClaireDreaErinFrankFrankieJessJesperJoelJuliannaKatieLexieMercedes-MFT InternParkerStephanieZach
Are you willing to be seen by a master's level intern? Interns are directly supervised by a fully licensed therapist with specific training in supervising other therapists. Interns are able to accept some Medicaid insurance plans as well as sliding scale fees from $10-$75 per session. : YesNo
Please briefly tell us what brings you to therapy.
What is your availability for appointments? (The more availability you have the more likely we can match you with a therapist.))
Anything else you like us to know?
If the prospective client is a minor select all which apply: "Parents are married" "One parent has sole custody" "Parents share joint custody" "There is not a legal custody agreement"]
If both parents have legal rights, please list the other parents: Legal name: email address: phone number:
If you are inquiring about relationship/family therapy, please provide for all other participants: Affirmed name(s): Legal name(s): Email address': phone number(s):
Would you like to be added to our email list and receive the Wild Ferns Wellness Center Newsletter? *You will receive email only, not physical mail. YesNo
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. 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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