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Pre-Intake Form

Want to expedite the intake process?

Please fill out this form to completion for a therapist to review.
This will help us verify benefits quickly.
Once insurance benefits are verified we will reach out to you.

*If you would like therapy for for more than one person, please fill out a form for each person.

*Appointments are based on time availability, insurance, and therapist skills

Thank You!

* Indicates required field

Name *

First

Last

Email *

Your Phone Number *

Your First Choice of Therapist (Not all therapists accept the same insurances, see clients in person, or see all ages of clients) *

Your Second Choice of Therapist In Case First Choice Has No Availability *

Is this Therapy Request for You or Someone Else? *

If for someone else, who (name/relationship to individual & age of individual) *

If for someone else, what is their date of birth? *

How did you hear about Prosperity Counseling & Supervision? *

What is your preferred contact method? *

Do we have permission to text you regarding scheduling? (By selecting yes, you are indicating your phone has sufficient security to ensure your privacy) *

What is a secondary way we can contact you? *

Do we have permission to email you regarding scheduling? (By selecting yes, you are indicating your email has sufficient security to ensure your privacy) *

If client is a minor *

I have legal custody I share legal custody There is a court order determining legal custody

Therapy location preference (Not guaranteed) *

What are all available days and times that you can receive a phone call/text regarding scheduling? *

You/your child's insurance type or self pay (Not accepting Meridian Medicaid, Molina Medicaid [Not including Molina Marketplace], United Health Community Medicaid, Aetna Medicaid, Humana, Medicare, HAP, or Tricare.) *

Date and times you/child/teen/family/partner are willing to commit to therapy. (Please note, your availability may not match with a therapist due to lack of availability) Example: Mon 4PM, Wed 9AM - 11AM, 4PM - 6PM, M-F 10AM - 12PM *

Have you/child/teen/partner been in therapy before? *

Have you/child/teen/partner ever been given a mental health related diagnosis? If so, what? *

Are you/child/teen/partner taking medication for a mental health related diagnosis? If so, what? *

Have you/child/teen/partner ever had an impatient mental health stay, partial hospitalization, or intensive out-patient treatment? If so, what was the reason, and when? *

What is bringing you/child/teen/partner to therapy? (Anxiety, depression, relationship issues, trauma, etc) *

If you/your child/your teen are experiencing suicidal or homicidal thoughts and you/your child/your teen plant to act on those thoughts, Please:
*Go to the nearest ER
*Dial 911
*Call Washtenaw Crisis line @ 734-544-3050
*Text the Suicide Hotline @ 988

Please upload pictures of your ID (Yours, Parent/Guardian) Front and Back
&
Insurance Card Front and Back (Yours, child's, teen's, dependent adult's) to verify benefits

We only accept:
*Aetna Commercial
*Blue Cross Blue Shield Commercial
*Blue Care Network
*Blue Cross Complete Medicaid
*Cigna/Ever North Commercial
*McLaren Medicaid
*Molina Marketplace
(Molina Medicaid is no longer accepted in Regions 7,8, and 9 of Michigan. Our clinic is in Region 9)
*Priority Health Commercial
*Priority Health Medicaid
*United Healthcare Commercial

Primary Insurance

Front of ID *

Max file size: 20MB HEIC files can't be opened. Please don't upload a HEIC file.

Back of ID *

Max file size: 20MB HEIC files can't be opened. Please don't upload a HEIC file.

Front of Insurance Card *

Max file size: 20MB HEIC files can't be opened. Please don't upload a HEIC file.

Back of Insurance Card *

Max file size: 20MB HEIC files can't be opened. Please don't upload a HEIC file.

Do you have secondary insurance? Note: Secondary insurance may not pay for costs primary insurance does not cover. Secondary insurance may not be billed due to therapist not being credentialed with secondary insurance *

Yes No

Secondary Insurance

Front of ID *

Max file size: 20MB

Back of ID *

Max file size: 20MB

Front of Insurance Card *

Max file size: 20MB

Back of Insurance Card *

Max file size: 20MB

If unable to upload pictures to this form or the pictures are HEIC files,
please email Andrea Abadie, M.S., LPC at [email protected].
Thank you!

Please give us at least 2-5 business days to verify benefits.
Once verified, Andrea Abadie, M.S., LPC will
reach out to you to discuss any financial responsibilities.
Thank you for your patience!
-Prosperity Counseling & Supervision, LLC

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Reach Out to Us

Pre-Intake Form

Please upload pictures of your ID (Yours, Parent/Guardian) Front and Back&Insurance Card Front and Back (Yours, child's, teen's, dependent adult's) to verify benefits

Primary Insurance

Secondary Insurance

Please upload pictures of your ID (Yours, Parent/Guardian) Front and Back
&
Insurance Card Front and Back (Yours, child's, teen's, dependent adult's) to verify benefits