New Client Registration Form

Behavioral Health New Client Registration Form

Corktown Health
1726 Howard Street Detroit, MI 48216
Phone (313) 832-3300. Toll Free (888) 435-5655 Fax (313) 832-3393
This form helps us understand your needs and connect you with the right support.

Please note: Corktown Health is not a crisis center. If you are in crisis or need immediate assistance, help is available:

Call or text 988 for the Suicide & Crisis Lifeline

Common Ground: Oakland County 24 hour crisis line: 800-231-1127

Wayne County Centralized Access 24 hour crisis line: 800-241-4949

Macomb County CMH Access Center 24 hour crisis line: 586-307-9100
Legal Name*

First NameLast Name
Preferred Name (if applicable)

First NameLast Name
Date of Birth*
MaleFemale
What pronouns do you use?
How were you referred to Corktown's Behavioral Health Services program?*
Are you receiving services from Corktown Health? If so, please list
Please enter your current address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Upload a photo of the FRONT side of your ID. NOTE: If you do not upload your ID you will need to provide a copy to your provider BEFORE your session.

Cancelof
Upload a photo of the BACK side of your ID. NOTE: If you do not upload your ID you will need to provide a copy to your provider BEFORE your session.

Cancelof
Who is your insurance provider? Please note if you have no current insurance. *
Insurance ID # (To move forward with therapy services, we must have your insurance plan information)
Insurance Group # (To move forward with therapy services, we must have your insurance plan information)
Upload a photo of the FRONT side of your Insurance ID card NOTE: If you do not upload your insurance id card you will need to provide a copy to your provider BEFORE your session.

Cancelof
Upload a photo of the BACK side of your Insurance ID card NOTE: If you do not upload your insurance id card you will need to provide a copy to your provider BEFORE your session.

Cancelof
If insurance is under another individual - please provide that person's legal name and date of birth.

Days and times your are available for sessions (Please check all that apply) At this time we are unable to offer evening appointments. *

Rows	Morning	Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday

In person - face to faceVideo Teletherapy sessions
DetroitHazel ParkN/A
I am a first responderI am the spouse / partner of a first responderI am an immediate family member of a first responderN/A
What is your profession?*
DepressionAnxietyPTSD or Complex TraumaBipolarSchizophreniaHistory of HospitilizationSuicide attempt or self-harm behaviors within the last 90 daysPrescribed psychotropic medicationsStruggling with substancesOtherN/A
Do you have any specific needs regarding your mental health provider (race, gender, skill-set)
By signing below, I attest that I have provided the correct Insurance information. I agree to allow Corktown Health to contact and verify my insurance and eligibility and benefits. In the event my Insurance coverage changes, I agree to inform Corktown Health staff of these changes and provide proof. I authorize Corktown Health staff to use all of the methods of contact I've provided to reach me regarding behavioral health services.
Signature*
Date*

MonthDayYear
Date
After you have signed and dated this form, please click submit. Thank you!
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