Affirmations Therapy Interest Form
**PLEASE NOTE THAT DUE TO THE HOLIDAYS RESPONSE TIME IS DELAYED** Thank you for your interest in our therapy services. Due to high demand and limited clinician availability, all of our services currently have a wait time. We have a waitlist for both in-person and virtual sessions, and we cannot guarantee immediate availability. However, we will do our best to accommodate your needs as soon as possible. If you would like to be added to our waitlist, please complete the following form. For additional assistance or referrals to other providers, feel free to reach out to us at therapy@goaffirmations.org or call us at 248-398-7105 for more information.
Name
*
First Name
Last Name
Pronouns
*
She/Her
He/Him
They/Them
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Is it okay to leave a detailed message stating that someone from Affirmations is contacting you?
*
Yes
No
Email
*
example@example.com
Preferred Method of Contact
*
Phone
Email
What kind of service are you seeking at this time?
*
Individual therapy for an adult
Individual therapy for a child
Family therapy
Couples therapy
In a few words, let us know what you are looking to speak to a clinician about. This will let us best match you with a clinician.
*
On a scale from 1 to 10, with 1 meaning not at all and 10 meaning completely, how much are your current symptoms affecting your quality of life or ability to meet daily needs?
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.
*
In-person
Virtual
Either
What is your availability like at this time to be seen by a clnician? (Please select all that apply)
*
Monday- Friday Mornings
Monday-Friday Afternoons
Will you be using insurance? If yes, please provide the name(s) of your insurance provider(s) and specify if it is commercial, Medicaid, Medicare, or a combination. If you have multiple health insurance plans, we will need details for each one. Additionally, please send pictures of all insurance cards before we proceed.
*
Insurance member number or ID number
*
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.
*
Yes
No
Is there anything else that you think we should know or that we should keep in mind?
Next Steps:
You will receive an email for an online therapy portal system called "Simple Practice", and forms need to be completed prior to assignment to a clinician. If portal forms are not completed you can be responsible for costs of treatment.
Submit
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