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Wayne State University
Mental Health and Wellness Clinic Client Form
Mental Health and Wellness Clinic
Fields with asterisks (*) are required.
Date of Birth
Preferred contact information
If you answered other to preferred contact information, please state preferred contact information
May we leave a message (if phone number)?
May we leave a text message (if phone number)?
Date of Birth
For persons under the age of 18, please indicate if you are
If answered other above, please state relationship to person under 18.
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).
American Indian and Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian and Other Pacific Islander
Do you have a preferred language? Please specify
We will do our best to meet your availability, however days and times will vary by therapist. Please indicate best availability
Type of Service (check all that apply)
What are the main symptoms that you are struggling with and want to talk about?
Please check some of the main challenges/concerns you are experiencing (Check all that apply)
Child behavioral problems
Recent changes causing stress
School/ Academic issues
Self – Harm
Do you have any other requests?
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?
Online, social media, TV advertisement, etc.
Friend, family, community members
University faculty, staff, etc.
Counseling and Psychological Services (CAPs)
If you selected other above, please state how you learned about MHaWC.
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: firstname.lastname@example.org. We will be contacting you, through your preferred contact. Please watch for emails from email@example.com.