The Therapy Collective of Michigan Send Message

Who would be receiving care?

Your info

For insurance verification
Select the state you live in
Reason for care
Limited to 600 characters
Administrative
Enter how you were referred to our services
Do not upload sensitive financial information such as credit card information.
Billing & Payment
How do you plan to pay?
Include all insurance information. Include the name of the primary insured, the relationship to the client, and the primary insured's DOB. NOTE: You MUST provide us with information for ALL insurance policies the client is covered under.
Limited to 600 characters
Upload a photo of your insurance card
Client Preferences
For example: what you'd like to focus on, insurance or payment questions, etc.
Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.