New Client Form

Welcome!

Hi there,

Thanks for your interest in therapy. Unfortunately, at this time my schedule cannot accommodate any new clients until January 2023. Please feel free to still complete a form if you would like to be placed on the wait-list. Alternatively, my colleague at Wellspring Connection has a male therapist taking clients currently. Thank you for your understanding and I hope to be in touch soon.

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

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:

*Please pick free consult time here, then submit form, thank you!

Your information will be encrypted.

Hours of Operation

M-W-Thu virtual sessions from 11a-7p Tuesday in person in Troy from 11a-7p Fridays by appointment only