UM-Flint - Counseling Services - Provider Information Form

Name of Clinic/Provider *
Discipline and Credentials
Address *
City *
State *
Zip Code *
Phone Number *
Fax Number
E-mail Address
Website Address
Service Provider(s): If you have more than 10 providers at your clinic, please feel free to mail us any additional information (i.e., brochures, business cards) at the address below.
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Specialty Areas: (please check all that apply) * ADHD Anxiety Disorders Body Image Career Counseling Couples/Marital Therapy Dissociatve Disorders Divorce/Separation Domestic Violence Eating Issues Family Therapy Gender Issues Grief/Loss Learning Disabilities Men's Issues Mood Disorders Personality Disorders Psychotic Disorders Sexual Assault/Trauma Sexual Disorders Sleep Disorders Somatoform Disorders Spirituality/Religion Substance Use/Abuse Trauma/PTSD Women's Issues

Other areas of Specialty: Please Fill in

 

Days/Hours of Operation (please indicate a.m. and/or p.m. in your response)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Fees: (please indicate if you provide a sliding scale fee structure)
Types of Insurance Accepted:
Therapeutic Modalities: Couples Family Group Individual
Description of Services provided: (Mail additional sheets as necessary)

Feel Free to mail us your clinic brochures/business cards at following address:

 

University of Michigan-Flint
303 E. Kearsley St.
Student Development Center
Counseling Services
264 University center
Flint, MI 48502

Phone: (810) 762-3456
Fax: (810) 762-3498

 

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