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Wayne State University
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MHaWC_Art Therapy
Mental Health and Wellness Clinic
Fields with asterisks (*) are required.
Preferred contact information
First name
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Last name
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Email
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Phone Number
Preferred contact information
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Phone
Email
Other
if you answered other above
May we leave a voicemail (if phone number)?
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Yes
No
May we leave a text message (if phone number)?
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Yes
No
What is your preferred session time frames? (Please check all that apply)
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Weekday Morning
Weekday Afternoon
Weekday Evening
Weekends
Do you have a computer?
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Yes
No
Do you have internet access?
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Yes
No
What is your preferred method of therapy?
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Phone
Phone FaceTime
Computer Face-to-Face via Zoom (software not required, we will invite you to the meetings)
What are the main symptoms that you are struggling with and want to address?
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What would you like to achieve with art interventions?
What materials do you have to make art? For example, do you have paper, something to draw with, magazines, glue sticks, scissors, yarn, cardboard, paint, etc.?
Do you require any special accommodations in order to work with art materials?
Do you have any other requests?
To participate in Telehealth services, it is necessary that you have reliable telephone/cell service and/or access to a reliable internet connection, and be able to meet in a private and quiet location. Please confirm that you have these capabilities.
*
I confirm
Date of Birth MM/DD/YYYY
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