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. I am currently accepting private-pay at this time (no insurance).
Full Name
*
First Name
Last Name
Date of Birth
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Do you currently live in Michigan?
Yes
No
Please describe the reason for seeking mental health services:
*
Preferred Appointment Date and Time
Digital Signature
*
Submit Inquiry
Submit Inquiry
Should be Empty: