Items with an asterisk (*) are required.
*Completing form for: SelfChildOther
*If "Child" or "Other" was selected above, please provide your name and relationship to client or type "self":
*Patient's First and Last Name:
*Patient's Date of Birth
*Preferred Phone Number:
*Can Stepping Stones Wellness Center leave a message when calling the patient'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
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
*Health Insurance Provider: No Health InsuranceAetnaBlue Cross Complete of MichiganBlue Care NetworkBlue Cross Blue ShieldCofinityHAPMedicareMedicare Plus BlueMultiplanPriority HealthPrivate PayOptumOut of NetworkUnited HealthcareUnknown
*Preferred Therapist or Group: MUST MAKE SELECTIONNo PreferenceMeagan Brooks, LLMSWJoumana Hussein, TLLPLinda 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: