Please answer the following questions about the person who will be the therapy client.
Affirmed Name
Legal Name (if you start therapy with us, this helps us set up your account properly.
Pronouns
Email
Phone number
Age
Ethnicity (optional-if do not want to answer write NA):
If you are inquiring about services for someone else what is your name, email address and relationship to the prospective therapy client?
We cannot legally provide therapy across state lines. Do you understand you must physically be in Michigan during telehealth appointments? YesNo
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 appointments onlyIn person appointments onlyTelehealth or in person, which ever option will get me scheduled the soonest
Who is your preferred therapist, if any? SCROLL TO VIEW & SELECTNo preferenceAnnie-MFT InternAva-MSW InternCassieClaireFrankJessJesperJoelJuliannaKatieLexieMercuriMercedes-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. Currently, our wait times for interns are much shorter than licensed therapists. Interns are also able to accept some Medicaid insurance plans as well as sliding scale fees of anywhere from $10-$75 per session.: YesNo
Please briefly tell us what brings you to therapy.
Would you like to be added to our email list and receive notice of Wild Ferns Wellness Center news, events, specials, etc.? *You will receive email only, not physical mail. YesNo
Is applicable, which primary 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 PlanOtherNot using insuranceMy insurance is not listed here, I would like to see about using out of network benefits
If applicable, which secondary health insurance plan do you have? CLICK HERE TO SELECTI do not have 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 PlanOther
What is your availability for appointments?
Anything else you like us to know?
Is it okay for us to email you? YesNo
Is it okay for us to text you? YesNo
Is it okay for us to call you? YesNo
If we contact you by email, text or phone would you like to be addressed by your affirmed name or legal name? AffirmedLegalUnknown-I am not the prospective client
If we contact you by postal mail would you like to be addressed by your affirmed name or legal name? We only send mail if there is an overdue balance an your account and we have been unable to reach you via your above selections (email, text & phone) AffirmedLegalUnknown
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.
