New Client Form

Hi there,

Thanks for reaching out, I will be taking new clients again after the New Year. You are welcome to complete this form if you would like to be placed on the wait-list and I will then contact you once spots become open after 1/1. We also have a late Winter Men's Retreat on the weekend of 2/24 in Ortonville, MI as another option for support and men's work. Thanks for your understanding and I apologize for the wait at this time.

Happy Holidays and 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)

Online Monday/Wednesday/Friday

Tuesdays (in-person)

Thursdays (in-person)

Late mornings (10a-12p)

Afternoon (12-4p)

Evening (4-8p)

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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Welcome!

Hours of Operation