New Client Form

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

Client Information

Hi there,

Thanks for your interest in therapy. Please fill out the form below and also pick your consult time with link at the bottom and we will meet from there to get you started. At this time, there may be a wait to get into evening appointments.

Thank you and I look forward to meeting with you!

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? My practice will continue to stay majority online with 1-2 days per week in person in Troy..

Video/Online only please

In-person only

Hybrid/Mix of both

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