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.
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?
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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