New Way Counseling Waitlist

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This form provides me with basic contact information and a general idea of your waitlist needs. This form does not guarantee services as a consultation phone call and determination of fit are still required to proceed with the therapy process.

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E-Mail-Adresse *

Your Full Name *

Your Best Phone Number *

Your best personal email *

Type of Therapy You're Seeking *

Individual Adult

Individual Teen (12-19 years old)

Couples

Family

Sonstiges:

Payment Method *

Blue Cross/Blue Shield

Aetna

United

TRICARE

Private Pay

Blue Care Network (BCN)

Sonstiges:

Major Issues You're Looking to Address (Select up to 3)

Sadness/Overwhelmed

Anxiety/Worry

Trauma

Anger

Alcohol

Food/Body Image

Relationship Struggles

Relationship Enhancement

Neurodiverse Experience Support

Work Related Stress

Issues with Parents

Women's issues (fertility, post partum)

Sonstiges:

Type of Service

In person (Grand Rapids)

Telehealth/Virtual

Combination

When can you meet for sessions (select all that apply)

Monday

Tuesday

Thursday

Friday

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

I understand that filling out this form does not guarantee me any timeline of therapeutic services. It is my responsibility to obtain appropriate services when needed. *

I agree

I understand that I may request referral options from New Way Counseling at any time while I am on the waitlist and will receive options to contact to find another therapist with sooner availability. *

I agree

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