Name*FirstLastThe person seeking treatment prefers to be called(First name, nickname, Ms. X, Mx. X, etc.)Age of person seeking treatment*I work with patients 16+Email*EmailPhone numberIssues of concern (check all that apply)*Academic or work problemsAngerAnxietyBipolar & mood disorderDepressionGeneral psychological stress or discomfortGrief & lossPhobia(s)Relationship problemsTrauma/PTSDOtherLocation of service*In Office (Suttons Bay)TelehealthInsurance and payment*MedicareBlue Cross Blue Shield PPOPrivate PayReferral source*GooglePsychology TodayDoctor referralInsurance Co.OtherIs there anything else you'd like me to know?Do not fill this field.