New Clients

New Client Forms

New Client Deposit Agreement Form

To use the fillable PDF form below, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. If you know how to electronically sign it, please do so. Otherwise print out the form and sign it. After completing and signing the form, please email the form or a photo of it to, fax to 734-477-5111 or mail to 2340 E. Stadium Blvd. Ste 8 Ann Arbor, MI 48104.

Please keep in mind that all new client intake forms are called back on a first come, first serve basis. In addition, both Herstory Form and New Client Deposit Agreement must be received in order to begin the process.

New Client Deposit Agreement

Once WomanSafeHealth has received your form and you have indicated that you prefer to use a credit card, the office staff will contact you to complete payment and set up an appointment. If you are using Paypal, or sending a check, money order, or cash with your new client deposit agreement, WomanSafeHealth will need to make sure your payment has cleared before the office staff will contact you to set up your new client appointment. If you have not heard from staff within 3 business days, please feel free to contact the office at 734-477-5100 or email us at

WomanSafeHealth Herstory Form

If you have a new client appointment, please fill out as much of this form as you would like to. We will complete your health herstory together when we see you for your appointment.

To use the fillable PDF form on this page, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. Please do not fill it out from an internet tab because your changes will not save.

WomanSafeHealth Herstory Form

After your changes are saved, you may return it to our office in one of the following ways:
1) bring the completed form to your appointment as a paper copy or on a jump drive, or
2) email the completed form to, or
3) mail the completed form to 2340 E. Stadium Blvd Ste. 8 Ann Arbor, MI 48104, or
4) fax the completed form to 734-477-5111

New Client Insurance Carriers

WomanSafeHealth is a fee for service practice meaning that we do not accept insurance and we require payment, at the time of service.
We always encourage clients to call their insurance provider well before their initial visit, to clarify what their benefits are for an OON (Out of Network) Provider.

It is helpful to be as specific as possible. Example: preventive care coverage. What does that cover exactly?
The following are questions to ask your insurance prior to your appointment.

  1. Do they reimburse for out of network doctors? If so, how much? Do they cover testing, specific bloodwork, urine cultures, radiology?
  2. Do they require a referral from an in-network provider in order to get reimbursement for WomanSafeHealth visits?
  3. If you know there is a specific test you’d like to have done i.e., check iron levels, toxicity tests etc. You can ask what it would cost you through insurance.
  4. If you know which testing you’d like to have done, WomanSafeHealth can give you an estimate print out to compare directly to insurance before you call.

It is required to know whether you will pay WomanSafeHealth or use your health insurance for testing at the time of service, not afterwards. WomanSafeHealth cannot change your billing preference for testing post appointment.

Clients Under 18 Policy

WomanSafeHealth is highly committed to protecting the privacy and confidentiality of all clients* including those less than 18 years old. Medical care or counseling that involves issues of birth control, sexually transmitted infections, pregnancy or substance abuse is kept confidential between the client and WomanSafeHealth provider as required by Michigan law.** Information about the medical care provided, including diagnoses, treatment and follow up for young clients will only be shared after written authorization from the client has been received. The fee schedule for medical care and other WomanSafeHealth services is the same for all, including clients under 18, and payment is expected at the conclusion of the appointment. We encourage all clients to make their own appointments. All clients are welcome to bring parents, friends or other support individuals to their appointments if they wish.

*WomanSafeHealth serves women, girls, trans and gender nonconforming people.
**WomanSafeHealth staff are mandated reporters when there is suspicion or evidence of child or elder abuse or neglect.

If you have any questions, please contact our office at 734-477-5100 or