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Name
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Address
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Email
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Parent or Guardian's Name
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Insurance Company
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Policy Number
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Why are you seeking counseling?
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Have you had counseling in the past?
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If you answered yes above, please list name of counselor.
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Dates seen by counselor:
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Are you currently in counseling?
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If you answered yes above, please list name of counselor.
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Dates seen by counselor & current diagnosis (if any):
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What service are you seeking?
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individual
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group
veteran's services
Payment
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self-pay
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need financial assistance
If you chose "agency funding" please fill in name of agency below:
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Agency Contact:
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Agency Contact Phone Number
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Who referred you?
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agency
counselor
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Referral Name:
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Agency:
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Phone Number
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Any additional information we may need to know:
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Thank you for contacting us. An intake specialist will be contacting you within 48 hours. If this is an emergency situation please contact Jennifer McVoy at 616.405.7986
IMPORTANT CONTACT INFORMATION:
Due to our location, our phone service is not always reliable. Please be sure to leave your e-mail address so we are able to contact you in a timely matter.
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