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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? *

If you give permission, you consent to receive messages from Prosperity Counseling and Supervision, LLC, 7344808099 regarding Customer Care. Message frequency varies. Message and data rates may apply. Reply STOP to unsubscribe or HELP for assistance. Privacy policy is available by request. *

What is a secondary way we can contact you? *

If client is a minor *

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

Therapy location preference (Detroit Location has a waitlist for in-person sessions) *

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
*submit form (send screenshots of the form and insurance and ID images via email)
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