All information that you provide us is completely confidential and secure. If you would prefer to do the initial contact over the phone, you can call 734.973.6779 and one of our staff members will take your information. Our phone hours are Monday – Friday, 9 am – 5 pm.

  • Contact Information

  • Emergency Contact

    Emergency contact will only be reached in the circumstance: we are unable to reach you by any of your provided means, we are concerned for your safety, or you experience a medical emergency while at our facility.
  • Insurance Information

  • If your answer is NO, please skip to the "Sliding Fee Information" Section.
  • Primary Insurance (skip if you answered "no" to the previous question)

  • Secondary Insurance (if applicable)

  • Sliding Fee Information

    Please fill out the following two questions if you're interested in paying based on your income (sliding fee). NOTE: This only applies to those not using Insurance to pay for services.
  • Other Information

  • Please check all that apply.