Contact

Therapy Request Form

New clients only- must complete the form below and submit their information, Once the form is submitted, you will receive an email from your prefered therapist inviting you to create an account and password at the telehealth portal. If you do not receive an email invitation within 24 hours of your request, send an email to admin@intervention-network.com. Only new patients can request a free 15 minute phone or video session to be sure online therapy is right for you.

Check your spam folder for the telehealth portal invitation. When your appointment is scheduled you will receive text messages and email reminders to be sure you don't miss your appointment.

Intervention Network Accepts

Medical FSA & HSA Cards and Employee Assistance (EAP)

Once your appointment is scheduled, you will be directed to the telehealth portal to create an account and pay for your sessions. Please schedule and pay for appointments in advance to secure your day and time. Invoices are provided for your convenience to document your medical expenses and may be used toward your insurance deductibles.

*Important, please read the cancellation and no show policy to the right of tis page.

THERAPY FORM REQUEST

Name

Date of Birth

Address, City, State, Zip Code

Email (required)

Phone (required)

Preferred Therapist

Please choose why you are interested in therapy-

Have you ever been in therapy before?

Provide a description of your symptoms, situation reason for therapy etc.

Select Counseling Session & Payment

I have read and agree to the refund policy to the right of this page.

Preferred Session Date

Select or type in preferred time

I give permission for text, email or voice message appointment reminders.

How I found this website

Cancellation policy

• Cancellation- Clients are required to text or email their therapist within 24 hours of their appointment to prevent a $30.00 late cancel fee.

• No Show- Clients who no show for a scheduled session will be assessed a $30.00 fee.

• Incurred fees- Clients who incur fees must pay them prior to scheduling another appointment.

• Subscription -Counseling is not offered by subscription. Each session is paid following your therapy session at Carepatron through Stripe a payment processing platform that accepts credit & debit MasterCard, Visa, American Express, Discover, HSA and FSA insurance cards.

Contact Information

•Main Phone 734.968.0218

•Fax- 734.884.5001

•Email- admin@intervention-network.com

EMERGENCY

We cannot respond to an emergency therapy reqeust.

Please, call your local hospital emergency room or

DIAL 911 for assistance with your emergency.

If you are feeling sucidial

DIAL 988

Intervention-Network

Online Counseling Services

THERAPY FORM REQUEST

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THERAPY FORM REQUEST

Intervention-Network

Online Counseling Services