Please complete the form below and send to us prior to your appointment. This is your new patient intake packet and will be sent directly to Derek Johnson, LMSW. You will not be seen without a new patient packet

Purpose of this questionnaire

This questionnaire was developed to obtain a comprehensive picture of you and your background. Your responses, combined with information discussed with your therapist/physician, lead to an assessment of you and your concerns. This will allow us to develop a plan to meet your needs and goals. As you can see the completeness of your responses is valuable to your therapy program.

All information obtained and submitted is strictly confidential. Your responses will be attached to your electronic medical record through our secured health link portal. Great Lakes TTC, LLC. complies with all state and federal guidelines regarding protected health information. This template will not allow you to save information and return to complete at a later time for security purposes. Please feel free to call with any additional questions.

Your new patient packet has been submitted. We will let you know if we have any questions or concerns, otherwise, we will see you at your scheduled appointment time & date. If you have any questions for our office, please feel free to give us a call at 231.487.6076. Our office hours are Monday through Friday from 9:00 am to 4:30 pm. Thank you again! We look forward to meeting you.