Request an Appointment If you are human, leave this field blank.Appointment Request FormInstructionsIf you are not a current patient and would like to request an appointment at our facility, please complete and submit the form below. If you are a current patient looking to schedule another appointment please call 810-630-1152. If this is an emergency please call 911 immediately. DISCLAIMER: This form is not meant to contain any Protected Health Information (PHI). Patient Name (First and Last): *Patient's Age (Not D.O.B.): *Phone Number *Insurance *Please visit our Pricing and Insurances page (at top of page) to make sure that our clinic accepts your insurance before submitting your request. Private pay options are available for those upon request.I have an active insurance plan that your facility accepts.I do not have an active insurance plan that your facility accepts and would like to discuss private pay options. Reason for Appointment *Please check all that apply:Psychiatric Evaluation/Medication ManagementPsychological EvaluationNeuropsychological EvaluationFitness for Duty EvaluationPre-Employment ScreeningPre-Bariatric EvaluationPre-Spinal Implant EvaluationAdult TherapyChild TherapyFamily TherapyCouples TherapyForm Completed By:Please select one of the following:I am the patient.I am the patient's parent or legal guardian.I am the patient's case manager.Other.Parent/Legal Guardian: *Please provide your name in the field below.Other(s) Name: *Other(s) Relationship to Patient: *Captcha *reCAPTCHA is required.Submit Appointment Request
