New Client Form

Metro-Detroit Men’s Therapy

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Hi there,

Thanks for reaching out, I will not be taking on new clients until January 2025, please feel free to fill out a consult form and I would be happy to connect in the New Year to get you situated. Thank you and have a great Holiday Season.

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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