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.

	Name:	Title:
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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: CouplesFamilyGroupIndividual

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

Need assistance with this form?

Counseling, Accessibility, and Psychological Services
264 UCEN
Phone: 810-762-3456

Fax: 810-762-3498

TTY: 810-766-6727

Spring 2013 Office Hours

Monday - Friday

8:00am - 5:00pm

University of Michigan-Flint

UM-Flint - Counseling Services - Provider Information Form

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