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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

First name *

Last name *

Email *

Date of Birth *

Phone number

Preferred contact information *

Phone

Other

If you answered other to preferred contact information, please state preferred contact information

May we leave a message (if phone number)? *

Yes

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

Yes

Client Information

First name *

Last name *

Date of Birth *

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

Parent/Legal guardian

Other

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)

Female

Male

Non-Binary

No Preference

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

Arab-American

Asian or Asian American

Black or African American

Latino/Latinx

Native Hawaiian and Other Pacific Islander

White/Caucasian

No Preference

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 *

Daytime

Evening

Anytime

Preferred modality *

Telehealth (video)

In-office/In-person

No preference

Type of Service (check all that apply) *

Adult-Individual Therapy

Child/Adolescent-Individual Therapy

Couples/Relationship Therapy

Family Therapy

Group Therapy

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)

Anxiety

Attention/Concentration issues

Child behavioral problems

Depression

Eating disorders

Financial stressors

Grief/Loss

Mood swings

Psychosis

Substance abuse

Trauma

Panic

Parenting issues

Relationship/Couple/Marital issues

Recent changes causing stress

School/ Academic issues

Self – Harm

Self-Destructive behaviors

Social anxiety

Suicidal thoughts

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).

Yes

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)

Other

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.

I confirm

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