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Charis Counseling Services of Northeast Michigan, PLLC

Rachel Achatz, MA LPC NCC

Welcome to Charis Counseling!

I use this form to gather information about you and the concerns you are currently experiencing to help me explore whether or not I may be the most suitable therapist to help you with your concerns. At this time, I have transitioned the focus of my practice to work primarily with couples and families. Additionally, I provide co-parenting counseling as well as parenting classes. I do see adolescents and adults with mood and anxiety disorders on a limited basis who wish to integrate their faith into their counseling sessions.

Please note that I am unable to return phone calls for new patient inquiries until the following form has been filled out. If it appears that I'm not the most suitable therapist for your concerns, I will send you a confidential email which will also include referrals to some colleagues who either work in the same building with me or other colleagues in the Northeast Michigan area who may be better suited to help you.

Due to my practice schedule, please allow 2 business days for a return email or phone call.

With warmest regard,

Rachel

Are you filling this form out for someone else?

Yes No

Name of Person Filling Out the Form

(If you are not the potential client)

Potential Client's First and Last Name

Date of Birth

Services Please select the services that you are inquiring about:

Couples Counseling

Family Counseling

Coparenting Counseling

Individual Counseling

Parenting Classes

Other

Email address

Phone Number

Street Address

City

State

Postal Code

Please share a little bit about your situation and what you would like to see happen in counseling:

In-Network Insurance

I am currently in-network with the following insurance companies:

Aetna
Blue Cross Blue Shield (not Blue Care Network)
Priority Health

Rachel participates with Tricare, but is not in network. If the client has Tricare, it is recommended that a prior authorization for counseling services be obtained from the client's Primary Care Manager in order to reduce out of pocket costs.

Out-of-Network Insurance

Rachel does not accept Medicaid or any of the Medicaid Managed Care Plans for Services.

For other insurances, Rachel will provide a superbill for client to utilize to seek out of network reimbursement from their insurance company.

Private Pay

For those who wish to opt out of their insurance coverage due to high deductibles, confidentiality, or other reasons, I provide a 20% discount off my customary rates. A form opting out of insurance coverage is required prior to receiving the discount. This discount is also available to those who do not have insurance.

I do reserve a few slots per month for those clients who are indigent and referred by their pastor. Proof of income is required prior to services being provided.

Couples or Co-parenting Counseling

It is important to note the majority of insurance companies do not reimburse providers for couples counseling. At least one individual in the relationship must be diagnosed with a mental health condition. In addition, the mental health condition must be affecting functioning of the individual to such an extent that family therapy is considered a "medically necessary" part of the individual's treatment.

Co-parenting Counseling is not considered a covered service by the above insurance companies under any circumstances.

Co-Parent's First and Last Name

Coparent's Date of Birth

Coparent's Phone Number

Coparent's Email

Please Upload a Copy of the Court Order for CoParenting

Add file

Please upload a file

Do you wish to use insurance?

Yes No Maybe

(Charis is in-network with my insurance, but I'm not sure I want to use it, or if the service is covered).

Insurance ID Number:

Group Policy Number

Primary First and Last Name

Primary Subscriber Date of Birth

Do you have secondary insurance? Rachel does not accept Medicaid or any Medicaid Managed Care Plans

Yes No

Secondary Insurance ID Number:

Secondary Group Policy Number

Secondary Subscriber Name

Secondary Subscriber DOB

Please upload a copy of the front and back of your insurance card(s)

Add file

Please upload a file

Please upload an image of the front of your insurance card

Image

Thank you for taking the time to fill out the above information. I will do my best to get back with you within 2 business days.

Sincerely,

Rachel Achatz, MA LPC NCC

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New form

Charis Counseling Services of Northeast Michigan, PLLC

Welcome to Charis Counseling!

In-Network Insurance

Out-of-Network Insurance

Private Pay

Couples or Co-parenting Counseling

Charis Counseling Services of Northeast Michigan, PLLC

Rachel Achatz, MA LPC NCC

Licensed Professional Counselor