Schedule an Appointment 
Thank you for reaching out!  Please answer the following questions so I can understand your needs.  I look forward to hearing from you and will be in touch soon.  
Warmly,
Lisa 
Sign in to Google to save your progress. Learn more
Email *
What is your name?  *
Which city and state do you live in?  (I am licensed to see therapy clients who live in Michigan and Indiana.  I offer coaching services for clients who live outside of Michigan and Indiana.) *
Which services are you interested in?  Please check all that apply.   *
Required
How did you hear about me?  *
I see clients on Mondays, Wednesdays, and Fridays.  What times are you available to meet?  Please check all the times you are typically available.   *
Required
How often are you hoping to meet?  *
Please confirm that you understand I do not bill insurance.  Payment is collected at the time of service by charging your credit card on file. Fees are $220 for sessions before 3pm and $250 for sessions after 3pm.   If you are seeing me for therapy services, I can provide you with a SuperBill (a detailed receipt) to submit to your insurance if they offer reimbursement benefits for mental health therapy.   *
Please confirm that you understand I meet with clients online through a HIPAA compliant online platform and do not meet with clients in person.  
*
Please share your top three goals in working together.   *
If you have any questions, please share them here and I will get back with you soon.  
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report