New Client Form

Welcome, I am glad you're here and congrats for taking the first step towards getting help.

Client Information

*Hi there, unfortunately I am currently full, if you would like to be put on the wait list, please fill out the form below. You are also welcome to schedule a free consult if you would still like to see if we would be a good for for therapy in the future.

Thank you,

Mike

Welcome, please complete the form below ***and also select your free consult time with the link at the end of the form. Thank you and I look forward to speaking with you!

First name

Last name

Date of birth

Cell phone number

Email address

What brings you to therapy/what are your current biggest concerns?

Are you comfortbale with online/video sessions for therapy? * I am only seeing clients via video sessions projected until June-July 2021, and then will have limited in-person visits in Troy **Please also specify below if you are just looking for therapy or if you're interested in joining the men's group as well.

Yes

No, but please contact me when you're back in-person

I am also in interested in men's group

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:

***Thank you, lastly, use link below to schedule your free consult and then submit form.

***Please use this link to schedule your free consult, then submit form, thank you!

Your information will be encrypted.

New Client Form

Welcome, I am glad you're here and congrats for taking the first step towards getting help.

Client Information

Welcome, I am glad you're here and congrats for taking the first step towards getting help.

Metro-Detroit Men's Therapy