New Client Form

Hi there,

Thanks for reaching out, unfortunately the schedule is currently full and I am not presently taking new clients. Please feel free to complete a consult form if you would like to be placed on the wait-list and I will reach out when spots become available. Thanks for your understanding and I apologize for the wait.

Be well,

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 online or in-person visits or a mixture of both? I currently work in-person every Tuesday from 10a-8p in Troy with limited availability

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)

Late mornings (10a-12p)

Afternoon (12-4p)

Evening (4-8p)

Mondays (online)

Tuesdays (in-person)

Wednesdays (online)

Thursdays (in-person)

Friday lunchtime by appointment

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/orgnization below:

May I add you to my quarterly newsletter?

Yes No thanks

Your information will be encrypted.

New Client Form

Welcome!

Hi there,

Welcome!

Hours of Operation