New Client Form

Metro-Detroit Men’s Therapy

Please correct the errors described below.

Hi there,

Thanks for reaching out, at this time I am not able to take on new clients as my caseload is full.

You are 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.

If you're looking for a reset and some deeper work at the end of the summer, we just announced our Annual Men's Retreat, 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?

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

How would you like to pay for sessions?

*I currently take the insurances listed here. My cash rate is $175/session. Please note that at this time I am not paneled with Medicare or Medicaid.

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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Hours of Operation

Mon/Weds: Virtual sessions from 10a-7p Tu & Thurs: In person at Royal Oak Office Fridays virtual by appointment only

metro_detroit_mens_therapy
1320 N. Campbell Rd., Suite 6, Royal Oak, MI, 48067, US

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