New Patient Appointment Request Form

Completing form for:
SelfChildOther

*First and last name of person completing this form and your relationship to the patient (or type "self"):

*Patient's First and Last Name:

*Patient's Date of Birth

*Preferred Phone Number:

This preferred number will call the patient's:
CellHomeWorkParent

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

*Email Address:

This email address is for the patient's:
HomeWorkParent

*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

Please note: the insurance providers we accept for testing are Aetna, Blue Care Network, Blue Cross Blue Shield, and Priority Health.

*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, LLMSWLinda Marino, LLPZeina Mikhael, LLP, BCBA, LBAStacey 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 OnlyLinda Potter, LLP - Telehealth OnlyMichele Wilson, LLP - Telehealth Only

Additional information you want us to know: