BRAINS Private Pay Inquiry Form

Please fill out this form if you are from an agency or facility that would like to pay for services for a client. Submitting this form will not guarantee you an appointment. Our Private Pay Coordinator will reach out to you via email with our "Private Pay Agreement" and "Intake Questionnaire" forms. Once we get these back, we will send an invoice with estimated costs for services. If DHHS will be paying for services, we will need some sort of signed document confirming their intent to pay. If an entity other than DHHS will be paying, we require all payment in full prior to scheduling. Once all required documents are received, we will go over available dates and times for scheduling the service(s).

Demographic Information

Client's First Name

Client's Last Name

Client's Date of Birth

Client's Age

Client's Sex

Male Female

Client's Gender Identity

Male Female Non-binary Transgender Decline Other

Specify Other

Agency Name

Point of Contact Name

Relationship to Client

Contact Phone Number

Fax Number

Contact Email Address

Contact Mailing Address

*Please note that all further communication from BRAINS will go to the contact listed on this form. If the point of contact changes at anytime during the process, you are responsible for letting our Private Pay Coordinator know of the change and updating contact information.

Services Requested

Specify Other:

Please note that if you are requesting a service that is not listed above, it may not be a service that BRAINS offers. Our Private Pay Coordinator will reach out to let you know of other options if BRAINS would not be the best fit.

Testing Concerns

Does the client have involvement in any of the following:

SSI/Dissability

Court/Legal Involvement

Custody

Specify Involvement

Specify Reason for Retest:

Specify Other:

Please note: if the reason for the referral or primary concern is the determination of abuse/neglect, then the client should be seen by a trauma specialist such as the Children's Trauma Assessment Center or Easterseals Michigan.

To ensure our testing team understands the reason for your referral, please provide any additional context, notes, questions, clarification, etc. below that you feel is relevant to the case.

Please attach any records or documents that would be helpful for our providers to have prior to services. These can include school records, medical/behavioral records, CPS reports, police reports, court documents, etc.

Add file

Please upload a file

Thank you for filling out our Private Pay Inquiry Form. Our Private Pay Coordinator will reach out to you via email within the next few business days with additional forms that need to be completed prior to scheduling. Timeline for scheduling the evaluation will vary based on your access to client records and DHHS's ability to produce a document confirming intent to pay. We look forward to working with you!

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