CONTACT

Name *

First Name

Last Name

Phone

(###)

###

####

Location *

Current regulatory rules allow counselors to practice within the state(s) that they are licensed. Do you reside in Michigan?

Yes

No

Health Insurance *

Please indicate your understanding that it is your responsibility to verify the details of your behavioral health coverage with Blue Cross Blue Shield (i.e. deductible, co-payment/co-insurance, etc.)

I understand