Sign up for therapy

During this stressful time, you can start or continue therapy by video or phone. Just fill out the form below or call our office at 734.973.6779 between 9 am and 5 pm Monday – Friday. If you call outside of business hours, you can leave a message and someone will get back to you as soon as possible.
All information that you provide us is confidential and secure. (Questions not marked with a red asterisk are optional.)

Counseling request, R2T

  • Room to Talk currently accepts the following insurances: Medicare, Blue Care Network of Michigan, Blue Cross Blue Shield, Blue Cross Complete, and Meridian. You may also pay fee out-of-pocket. A third option is our sliding-fee Soundings therapy program, where clients pay what they can afford for counseling with graduate-student interns.
  • Contact information

  • Emergency Contact

    The emergency contact will only be reached in the following circumstances: 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

  • Primary Insurance

  • This phone number may be an 800 number on the back of your card.
  • Also known as "enrollee" ID. (NOT Group ID#.) Typically starts with letters, e.g. ZYX000123456)
  • This number may be about 8 numerals.
  • Secondary Insurance (if applicable)

  • (NOT Group ID#. Typically starts with letters, e.g. ZYX000123456)
  • Sliding-Scale Information

    If you do NOT want to use insurance and would rather pay a sliding-scale fee please fill out the following two questions.
  • Other Information