Affirmations Therapy Interest Form

Affirmations Therapy Interest Form
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.

Affirmations is not a crisis center. If you are in crisis or need immediate assistance, help is available:

Call or text 988 for the Suicide & Crisis Lifeline

Common Ground at 800-231-1127

The Trevor Project at 1-866-488-7386

Trans Lifeline Hotline at 877-565-8860
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.*
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-personVirtualEither
What is your availability like at this time to be seen by a clnician? (Please select all that apply)*

Monday- Friday MorningsMonday-Friday Afternoons
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.*
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.
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