New Client Form

Hi there,

Thanks for reaching out, at this time I currently have a wait-list for new clients. I am usually able to get new clients in within 1-2 months. If you'd like to be placed on the wait-list, please fill out this form and I will reach out as spots open up. Thanks for your understanding and I apologize for the wait at this time.

Also, our 3rd Annual Men's Retreat in September is now open for registration, check it out here

Take care,

Mike

First name

Last name

Date of birth

Cell phone number

Email address

What brings you to therapy/what are your current biggest concerns?

Would you like to work with me online or in-person visits or a mixture of both? I currently work in-person every Tuesday and Thursday in Royal Oak, MI.

Video/Online only please

In-person only

Hybrid/Mix of both

I am also interested in men’s group and/or retreats

When are your preferred times to meet? (Select all that apply)

Online Monday/Wednesday/Friday

Tuesdays/Thursdays (in-person)

Early afternoon (10a-1p)

Afternoon (1-4p)

Evening (4-7p)

Therapy History

Have you been in therapy in the last 12 months?

Yes No

Were you referred by someone? if yes, please share their name/organization below:

May I add you to my quarterly newsletter?

Yes No thanks

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New Client Form

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