New Client Form

Hi there,

Thanks for reaching out, at this time my schedule is unable to accommodate new clients. If you'd like to be put on the wait-list please fill out a form below and I will reach out as spots become available. There is about a 2-3 month lead time at this moment. I apologize for the wait at this time and appreciate your patience and understanding.

*We also have a 1-day workshop on an Intro to Men's Work on 11/9/24, learn more here:

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 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

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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