• Affirmations Therapy Interest Form

  • Hello!

    Thank you for your interest in Affirmations Health and Human Services. Please complete the interest form to begin the intake process and be assigned to a clinician.

    **If you are looking for therapy and have Blue Care Network insurance or Medicare, please know that we do not have clinicians available at this time due to clinician licensing requirements**

    Affirmations is not a crisis center. If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency department.

    You can also:

    • Call or text 988 for the Suicide & Crisis Lifeline
    • Reach out to Common Ground at 800-231-1127
    • Reach out to The Trevor Project at 1-866-488-7386
    • Call the Trans Lifeline Hotline at 877-565-8860

    While we do our best to schedule new clients as quickly as possible, please note that therapy sessions are limited, and we are currently unable to guarantee same-day or same-week appointments. At this time, there is a wait to begin services, and we are unable to guarantee a specific timeframe for when you will be seen. Everything depends on clinician availability and scheduling needs, and this often varies.

    If you have any questions about this form, please reach out to Jen at therapy@goaffirmations.org or 313-230-4805.

    Thank you for your patience and understanding — we’re glad you reached out and look forward to supporting you.

     

  • Pronouns for Client*
  • How did you hear about mental health services at Affirmations?
  • Date of Birth for Client*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is it okay to leave a detailed message stating that someone from Affirmations is contacting you?*
  • Preferred Method of Contact*
  • Do you currently reside in the state of Michigan? Please know that if you live in another state, we cannot match you with one of our therapists, as we are only credentialed with clinicians in the state of Michigan.*
  • What kind of service are you seeking at this time?*
  • Do you have a preference for male or female presenting clinician? Please select below- you can also leave comments in the "notes" section:
  • Are you looking for in-person services, virtual, or either? Again, please note at this time we are very limited in having clinicians available for in person therapy.*
  • What is your availability like at this time to be seen by a clinician? (Please select all that apply)*
  • Do you have insurance you will be using for mental health coverage?*
  • Are you open to seeing a clinician in training (student)? All Affirmations interns are master's or doctoral-level students pursuing degrees in psychology, social work, or counseling and are supervised by a fully licensed mental health provider.*

  • *PLEASE READ*

    Next Steps

    You will recieve a portal invite for a platform called Simple Practice in the next 5-7 business days. These items have to be completed prior to being assigned. If there is any issue or you have any questions, please reach out to therapy@goaffirmations.org.

  • Optional:

    We are seeking updated information on nicotine use to meet grant reporting requirements and ensure continued funding. Accurate, current data is essential to demonstrate program impact and guide ongoing prevention and cessation efforts. Without this information, it becomes challenging to justify the effectiveness and necessity of continued support.
  • Do you currently use tobacco/nicotine products?
  • If you are a tobacco/nicotine product user, are you interested in quitting, or receiving support to quit?
  • What types of tobacco/nicotine do you use?
  • Should be Empty: