New Client Form

Hi there,

Thanks for reaching out, I currently have limited availability, however, Robert has joined our practice and is a seasoned therapist with over 15 years of experience. He has in-person openings for anxiety and depression concerns. He can take BCBS, Medicare, and private pay starting 8/4.

I also have a current Master's level intern, Stephen who is taking clients for discounted private pay sessions. Please select that option below if you would be open to this, he is a great clinician and is supervised by me.

Upon completion of the form, you will be offered times for a free consult in which I would be happy to chat and get you setup.

If you're looking for a reset and some deeper work at the end of the summer, we have our Annual Men's Retreat 9/18-9/21, 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?

How would you like to meet? Our in-person office is in Royal Oak, MI, Monday-Saturday

In-person only

Video/Online 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)

Mornings

Afternoons

Evenings

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

Your information will be encrypted.

New Client Form

Hours of Operation