Therapy Inquiry Form
Thank you for your interest in therapy. This form helps me understand your needs and determine if we're a good fit to work together. Completing this form does not guarantee services. All responses are confidential. Sessions held are via Telehealth and are private pay.
Full Name
*
First Name
Last Name
Date of Birth
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently live in Michigan?
Yes
No
Please describe the reason for seeking mental health services:
*
Are you open to self-pay sessions? Insurance is not currently accepted.
Yes
No
Preferred Appointment Date and Time
Digital Signature
*
Submit Inquiry
Submit Inquiry
Should be Empty: