Affirmations Therapy Interest Form

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.

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.

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
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.
Name*

First NameLast Name
Pronouns*

She/HerHe/HimThey/Them
Date of Birth*

MonthDayYear
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?*

YesNo
Email*
example@example.com
Preferred Method of Contact*

PhoneEmail
What kind of service are you seeking at this time?*

Individual therapy for an adultIndividual therapy for a childFamily therapyCouples therapyMedication ManagementLetter(s) for gender affirming care
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.*
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-personVirtualEither
What is your availability like at this time to be seen by a clinician? (Please select all that apply)*

Monday- Friday MorningsMonday-Friday AfternoonsMonday- Friday Evenings (After 5:00PM)- Please note that at this time we are limited on evening offerings!Weekends (Please know that at this time we are extremely limited on weekend offerings!)
Do you have insurance? If yes, please provide the name(s) of your insurance provider(s) and specify if it is commercial, Medicaid, Medicare, or a combination.*
**Please note that at this time, if you have Medicare or Blue Care Network insurance the wait is a little bit extended due to needing a licensed master's level provider per your insurance.**
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.*

YesNo
Is there anything else that you think we should know or that we should keep in mind?
*PLEASE READ*

Next Steps

You will receive an email for an online therapy portal system called "Simple Practice". Forms MUST be completed prior to assignment to a clinician. If portal forms are not fully completed we cannot place you with a clinician.
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?

YesNo
If you are a tobacco/nicotine product user, are you interested in quitting, or receiving support to quit?

YesNo
What types of tobacco/nicotine do you use?

CigarettesE-Cigarettes/JUUL/VapingSmokeless tobacco (dip,chew)Cigars or cigarillosOther
Should be Empty:

Affirmations Therapy Interest Form

Optional: