Appointment Request

Name (First & Last Name)

Phone Number

Date of Birth

State of Residence

Insurance Information

*Accepted Insurances include Blue Cross Blue Shield, Blue Care Network, Aetna, United Healthcare, Blue Cross Complete, Molina, Meridian. If cash paying client please enter N/A in this field.

Insurance Member ID/Policy Number

*If not using insurance please enter N/A in this field.

Policy Holders Name & Relationship

*If not using insurance please enter N/A in this field.

Policy Holders DOB

*If not using insurance please enter N/A in this field.

Reason for your visit

*Please advise if interested in individual, couples or family therapy.

After successfully submitting your request for assistance, our office will follow up based on your request. Do you agree to be contacted by Focus Therapy Clinic via phone, email, or text message from 248-430-0594 or info@focustherapyclinic.com? Message frequency varies and may include (appointment scheduling, billing, service follow-ups). Reply STOP at any time to end or unsubscribe. For assistance, reply HELP or contact us at 248-430-0594.

Consent to communication

Yes, I agree to communication No, I do not want communication

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