New Client Form

Hi there,

Thanks for reaching out, at this time I am not able to take on new clients as my caseload is full. Here are two of my colleagues who may have room in their practice:

https://myregenhealth.com/

https://bencampbelltherapy.clientsecure.me/

Alternatively, we do have an 8-week men's group starting in late Feb. and it is an excellent way to jump into men's work and also get support in a group setting. We cover all the same topics as we would in individual therapy with the added benefit of more in-depth practice time and longer sessions. Check it out here.

You are also welcome to complete a consult form below to secure your spot on the wait-list and I would be happy to reach out when spots become available.

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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