Are you inquiring about services for yourself or someone else? If someone else what is your name, email address and relationship to the prospective therapy client?
Please answer the following questions about the person who will be the client.
Affirmed Name (We will use this name when we contact you)
Full 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):
Which type of therapy are you requesting (Select all that apply)? : individual therapyrelationship therapy (family, couples, etc.)therapy for minor (under age 18)
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? CLICK HERE TO SELECTNo preferenceAnnie-MFT InternAva-MSW InternCassieClaireFrankFrankieJessJesperJoelJuliannaKatieLexieMercedes-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
Which primary insurance plan do you have? If you will be self-paying without insurance, select self-pay CLICK HERE TO SELECTSelf-PayAetna 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
In order for you to start therapy with us, we need to match you with a therapist. Ability to create a match is impacted by many factors, including your availability, if a therapist has openings, if the therapist is able to accept your insurance, if the therapist matches your preferences and more.
You may upload your insurance cards now or wait. Uploading your insurance cards now may speed up the intake process but ONLY IF we are able to match you with a therapist. Uploading insurance cards has NO IMPACT on us matching you. If we do not have a match, we will email you referral information.
Front of Primary insurance card
Back of Primary insurance card.
What is the insurance subscribers full name and birthdate?
What is your availability for appointments?
Anything else you like us to know?
We must be able to email you to complete the intake process. 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.
