New Client Appointment Request Form

Completing form for:
SelfChildOther

*If "Child" or "Other" were selected above, please provide your name and relationship to client or type "self":

*Client's First and Last Name:

*Client's Date of Birth

*Preferred Phone Number:

This preferred number will call my:
CellHomeWork

*Can Stepping Stones Wellness Center leave a message when calling the client's preferred phone?
YesNo

*Email:

*Assigned Gender at Birth:
FemaleMalePrefer not to say

*Pronouns:
He/HimShe/HerThey/ThemOther

*Marital Status:
DivorcedDomestic PartnershipMarriedSingleOther

*Is this court ordered therapy?
YesNo

*Is this a request for testing?
YesNo

*Reason for Seeking Therapy:

*Prefer In Person or Telehealth:
In-PersonTelehealthBoth

*Appointment Availability (check all that apply):
Weekdays 9am-3pmWeekdays 4pm-9pmWeekends 9am-3pm

Let us know if you need appointments on specific days and times:

*Health Insurance Provider:
No Health InsuranceAetnaBlue Cross Complete of MichiganBlue Care NetworkBlue Cross Blue ShieldCofinityHAPMagellanMedicareMedicare Plus BlueMultiplanPriority HealthPrivate PayOptumOut of NetworkUnited HealthcareUnknown

*Preferred Therapist:
MUST MAKE SELECTIONNo PreferenceMeagan Brooks, LLMSWJoumana Hussein, TLLPLinda Marino, LLPZeina Mikhael, LLP, BCBA, LBARasha Moslemani, LLPCStacey Narduzzi, LLPGenovia Peterson, LPCKeri Sanders, LLP, BCBA, LBAWilliam Sisung, LLPDima Swaidan, PsyD, LPJ Ryan Trapp, LPCDarryl Warner, PhD, LPRachel Noonchester, LLP - Telehealth OnlyLatasha Onwenu, LPC, CAADC - Telehealth OnlyStefanie Paquin, LLP, CAADC - Telehealth OnlyMartha Poenaru, LLP - Telehealth OnlyLinda Potter, LLP - Telehealth Only

Additional information you want us to know: