Client Registration Form

Already have a therapist and have your appointment scheduled? GREAT! You are in the right place!

IF YOU DO NOT HAVE A THERAPIST ASSIGNED PLEASE CLICK TO GO TO OUR THERAPY REQUEST FORM

We are looking forward to working with you on your journey!

If you have any questions don’t hesitate to call us at 269-262-1815.

  • Or if you booked your own appointment you may leave blank.
  • Please leave the name, birthdate, address and phone number of your spouse/significant other/parents (if applicable).
  • Please list any medications.
  • Please list the names and ages of others living in your household.
  • Please leave an emergency contact.
  • IF YOU HAVE MEDICAID THEN NO CREDIT CARD REQUIRED.
  • Enter Name of Patient or Authorized Representative Agreeing to the above terms.
  • Drop files here or
    Max. file size: 256 MB, Max. files: 2.
      PLEASE UPLOAD FRONT AND BACK OF YOUR DRIVER'S LICENSE
    • Drop files here or
      Max. file size: 256 MB, Max. files: 2.
        PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD
      • ***BEFORE SUBMITTING PLEASE MAKE SURE YOU UPLOADED INSURANCE CARDS AND DRIVER'S LICENSE***