Please note that our psychiatry providers do not complete, attest or verify any FMLA, disability, unemployment, work leave, legal, housing, work accommodations or benefits forms for new or existing patients. By checking YES below, you are agreeing to abide by our practice policy and will not ask your provider to complete, attest or verify any forms and paperwork for you. *

Yes

You must be physically located in Michigan at the time of your video session. Does this works for you? *

Yes

No

Who referred you to Skye?

Past patient of Darla Dane, PMHNP-BC

Past patient of Dr. Jennifer Sam, PMHNP-BC, DNP

Google

Psychology Today

Referred by therapist

Referred by family member

How soon do you need an appointment? *

Soon as possible

Next week

Not urgent

What insurance are you using? *

These are the insurances we currently accept . Currently we do not accept Medicare / Medicare Advantage or Michigan Medicaid / Healthy Michigan Medicaid plans.

Blue Cross Blue Shield of Michigan (PPO and HMO Plans)

Blue Care Network

MESSA (Michigan Education Special Services Association)

Anthem Blue Cross Blue Shield

Aetna

Cigna

United Healthcare

Optum

Carelon Behavioral Health

Quest Behavioral Health

Oscar

Oxford

ASR Physicians Care

Ascension SmartHealth

UMR

GEHA (Government Employees Health Association, Inc.)

Blue Cross Blue Shield of Massachusetts

Self-pay with Credit / Debit / HSA / FSA / FRA Card {First 60 minute session - $200; Follow-up sessions - $100.}

Who is the appointment for? *

First Name

Last Name

Date of Birth *

If the appointment is for a minor then use their date of birth

MM

DD

YYYY

Parent or Guardian Name who is completing this

Only if the appointment is for a minor

First Name

Last Name

Cellphone *

If the appointment is for a minor then use your cell.

(###)

###

####

Your Address

We need the residential address that your health insurance has

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How would you like to be contacted? *

Text

Email