Counseling Appointment Request | Evolve Therapy Group

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Don’t ignore your mental health. If you have a problem related to addiction, trauma, or anxiety, please complete the form below to schedule an appointment with our practice. The Evolve Therapy Group staff will try our best to accommodate your request and will be in touch as soon as possible.

Call Us

(616) 309-0737

Email Us

contact@evolvetherapygroup.com

Full Name*
Email Address*
Phone Number*
I am interested in*
Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking:*
Would you like to use insurance?*
Do you want to fill in more information to save time on your follow-up phone call?*
Address*
Street Address Address Line 2 City State ZIP Code
Insurance Company*
Group Number*
ID Number*
Payer ID*

This is often found on the back of the insurance card.
Who is the policy holder for your insurance plan?*
- Self
- Relative
Policy holder’s relationship to you*

(ie. parent, spouse, etc.)
Policy holder’s name*
First Last
Policy holder’s date of birth*
MM slash DD slash YYYY
Policy holder’s address*
- Same as mine
- Other
Policy holder's address*
Street Address Address Line 2 City State ZIP Code
Do you have a supplemental insurance plan?*
Supplemental Insurance Company*
Supplemental Insurance: Group Number*
Supplemental Insurance: ID Number*
Supplemental Payer ID*
Supplemental Claims Address (often found on the back of insurance card)*
Street Address Address Line 2 City State ZIP Code
Who is the policy holder for your supplemental insurance plan?*
- Self
- Relative
Supplemental insurance policy holder’s relationship to you*

(ie. parent, spouse, etc.)
Supplemental insurance policy holder*
First Last
Supplemental insurance policy holder's date of birth*
MM slash DD slash YYYY
Supplemental policy holder’s address*
- Same as mine
- Other
Supplemental policy holder’s address*
Street Address Address Line 2 City State ZIP Code
Additional details*
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Appointment Request

Request an Appointment

Call Us

(616) 309-0737

Email Us

contact@evolvetherapygroup.com

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