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.

  • Tell us about yourself

  • If not English, what language would be best for counseling? We will try to accommodate your language preference.
  • (e.g., social security app, job training)
  • Contact information

  • What days / times can you come to The Women's Center to receive personal counseling?
  • Emergency Contact Information

    Whom do we contact in case your phone is turned off or in case of an emergency? (They do not need to live in the state. The most important thing is that you feel comfortable telling this person that you are coming to The Women's Center for counseling.)
  • Insurance Information

  • If you answered "Yes", please provide us with your insurance information. If you answered "No", please scroll down to the next section.

  • (NOT Group ID#. Typically starts with letters, e.g. ZYX000123456)
  • Income

    If you are not using insurance, we will use this information to help set a rate that you can afford on a weekly basis.
  • Reasons for seeking counseling