Transformative Therapy & Consultation Services, LLC

Transformative Therapy & Consultation Services, LLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

You ethnicity (optional)

Administrative

Referral source

How to did you learn about us

A doctor or medical provider Google or web browser Social media Psychology Today Friend or family member Other

Driver's license upload

Do not upload sensitive financial information such as credit card information.

SKIP if not seeking therapy for MINOR. Which best describes the custody arrangement?

Parents are married One parent has sole custody Parents share joint custody There is not a legal custody aggreement

SKIP if not seeking therapy for MINOR. List the other parent/guardian's legal name, affirmed name (if there is one) and email address.

Limited to 600 characters

Billing & Payment

If using insurance, which insurance plan do you have?

Aetna Better Health Medicaid Aetna Commercial Blue Care Network Blue Cross Blue Shield Blue Cross Complete Medicaid of Michigan Meridian Medicaid Blue Cross Complete Medicaid Forest County Potawatomi Insurance Ingham Health Plan McLaren Commercial McLaren Medicaid Medicaid of Michigan Meridian Commercial Molina Commercial Priority Health Commercial Priority Health Medicaid Upper Peninsula Health Plan My insurance is not listed - I am interested in using my out of network benefits

Insurance card upload

Upload a photo of your insurance card

What is the legal name of the insurance subscriber?

What is the birthdate of the insurance subscriber?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.