Connection Survey
Please answer the following questions honestly so we can be sure we are a good fit for working together. I'm so grateful you are here and I look forward to learning more about you. After completion of this survey I will contact you to discuss next steps. Thank you!
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First & Last Name *
Email Address & Phone Number *
Will you be doing Telehealth appointments or coming to my office in Caro, Mi? *
What characteristics are you looking for in a therapist? How will you know if we are a good fit? *
What brings you to therapy now, and what are you hoping to get out of therapy?
What insurance are you hoping to use? I don't accept ANY insurances other than those listed below. So please note if you have another insurance provider your only other option would be to pay private pay rates.
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Do you have secondary insurance? *
Is your insurance medicaid? *
Have you been in therapy before? and if so, what did you work on in the past?
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Are you flexible with scheduling? At this time I have no evening or weekend availability, so I'd just like to make sure I could accommodate your scheduling needs. If you need weekend or evening availability please note that we would not be a good fit at this time.
 *
Where did you hear about our office from?
 *
Anything else you'd like to share, or any questions for me?
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