We're glad you're here. Complete this request form and our intake team will match you with a therapist based on your needs, preferences, insurance, and availability. Who are you completing this form for?* MyselfSomeone else Your information Please share your information as the person completing this form. Your name Your email Your relationship to the prospective client Prospective Client Information Affirmed name We will use this name when we contact you. If you leave this blank, we'll use your legal name until we hear otherwise. Full legal name* This helps us set up the client account properly. Pronouns* Email* Phone number* Age* Ethnicity, optional 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 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 Information for clients under 18 Please select all that apply: Parents are marriedOne parent has sole custodyParents share joint custodyThere is not a legal custody agreement If both parents/legal guardians have legal rights, please list the other parent/guardian's information: Legal name Email address Phone number Relationship/Family Therapy Participant Information The prospective client's information was collected above. Please enter information for any additional participants. How many additional participants will be joining therapy?* —Please choose an option—1 additional participant2 additional participants3 additional participants Additional Participant 1 Affirmed name Legal name Email address Phone number Additional Participant 1 Affirmed name Legal name Email address Phone number Additional Participant 2 Affirmed name Legal name Email address Phone number Additional Participant 1 Affirmed name Legal name Email address Phone number Additional Participant 2 Affirmed name Legal name Email address Phone number Additional Participant 3 Affirmed name Legal name Email address Phone number Therapist Preferences Do you have any therapist preferences? Select all that apply. Therapists of color currently have virtual appointments only. 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 type of appointment are you open to?* Telehealth onlyIn person onlyTelehealth or in person, whichever will get me scheduled the soonest 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?* Please include days, times, and whether you prefer morning, afternoon, or evening appointments. Payment Information How will therapy costs be covered?* —Please choose an option—InsuranceSelf-pay: Therapy with an intern for lowest rates ($0-$40 per session)Self-pay: Full rate ($225 per appointment)Self-pay: Apply for reduced rates ($80-$225 per session)Client is LGBTQ+, BIPOC, and 13–25 years old. I would like to apply for grant help. Insurance Information How many insurance plans will you be using?* —Please choose an option—One insurance planTwo insurance plans Not sure which plan is primary or secondary? That's okay. Please answer as best you can and our intake team will help verify your benefits. Your insurance plan Insurance plan name* —Please choose an option—Aetna Better Health (Medicaid)Aetna CommercialBlue Care NetworkBlue Cross Blue ShieldBlue Cross Complete MedicaidForest County Potawatomi InsuranceIngham Health PlanMcLaren CommercialMcLaren MedicaidMeridian CommercialMeridian MedicaidMolina CommercialPriority Health CommercialPriority MedicaidUpper Peninsula Health PlanInsurance not listed / I want to ask about out-of-network benefitsNot sure Is this plan primary, secondary, or are you unsure? —Please choose an option—PrimarySecondaryDon't know Please upload the front and back of your insurance card if you have it available. If you do not have it right now, our intake team can follow up by email. Front of insurance card Back of insurance card Insurance subscriber full name Insurance subscriber birthdate Second insurance plan Second insurance plan name* —Please choose an option—Aetna Better Health (Medicaid)Aetna CommercialBlue Care NetworkBlue Cross Blue ShieldBlue Cross Complete MedicaidForest County Potawatomi InsuranceIngham Health PlanMcLaren CommercialMcLaren MedicaidMeridian CommercialMeridian MedicaidMolina CommercialPriority Health CommercialPriority MedicaidUpper Peninsula Health PlanInsurance not listedNot sure Is the second plan primary, secondary, or are you unsure? —Please choose an option—PrimarySecondaryDon't know Please upload the front and back of your second insurance card if you have it available. If you do not have it right now, our intake team can follow up by email. Front of second insurance card Back of second insurance card Second insurance subscriber full name Second insurance subscriber birthdate Please upload the front of your identification or driver's license if available. If you do not have it right now, our intake team can follow up by email. Anything else you'd like us to know? If you have a specific therapist you would like to be matched with, you can add their name here. Next Steps 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 intake forms. Forms must be completed before your first therapy appointment. Consent to submit this form Please review and accept the statement below before submitting. 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. Δ
