Mental Health and Wellness Clinic Client Form

Mental Health and Wellness Clinic

Fields with asterisks (*) are required.

Announcement: The clinic will not be taking on any new clients after November 10, 2023, due to the winter break at Wayne State University. All new submissions will be seen starting after January 8, 2024.

Contact information

Preferred contact information *
May we leave a message (if phone number)? *
May we leave a text message (if phone number)? *

Client Information

For persons under the age of 18, please indicate if you are

Client and Therapist Information

Therapist Gender Preference (check all that apply; Although we value preferences we are training clinic and our therapists rotate on a semester basis, therefore cannot always guarantee requests)
Therapist Ethnic/Racial Preference (please note, we may not be able to guarantee your preference at time of request given we are a training clinic comprised of graduate students at various stages of their education and training).
We will do our best to meet your availability, however days and times will vary by therapist. Please indicate best availability *
Preferred modality *
Type of Service (check all that apply) *
Please check some of the main challenges/concerns you are experiencing (Check all that apply)
Are you currently a Wayne State University student? (Note: You do not have to be a Wayne State University student to receive services).
How did you learn about us?
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.

We will be contacting you shortly. If you have any immediate questions and/or concerns, please email us at: We will be contacting you, through your preferred contact. Please watch for emails from