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. Insurance credentialing is currently in progress. You are welcome to join the waitlist and will be notified once insurance paneling is complete and appointments become available. I am also accepting self-pay clients at this time.
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.
What health insurance provider do you currently have?
Do you currently live in Michigan?
Yes
No
Please describe the reason for seeking mental health services:
*
Are you open to self-pay sessions while insurance credentialing is in progress?
Yes
No
Preferred Appointment Date and Time
Digital Signature
*
Submit Inquiry
Submit Inquiry
Should be Empty: