Metro Detroit Men's Therapy

First Name *

Last Name *

Email *

Phone *

What services are you seeking? *

In-person therapy only

Virtual therapy only

Hybrid/mix of both

Mens Group

Retreats

Deep Dive

What are you looking to confront, address, and/or accomplish? *

Preferred Meeting Times

Mornings

Afternoons

Evenings

Saturdays

Therapy History

Yes

If yes, what was your past experience like? What was helpful and not helpful?

How would you like to pay for sessions? *

BCBS

BCN

Aetna

Priority Health

Tri-Care

United Healthcare

Medicare

Mike Private Pay ($175)

Robert Private Pay ($165)

Stephen Private Pay ($155)

Discounted Session ($65)

Family Sessions ($200)

Deep Dive

Preferred Therapist

Mike Lamerato

Robert Blender

Stephen Busscher

Britain Willcock

To help expedite the on-boarding process, you can attach your insurance card here on our secure and encrypted form. We will run a courtesy check on your benefits. This can be done later but will help with getting you into the system and into therapy faster if attached now. Thank you!

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

How did you find us or who referred you? *

May I add you to our quarterly newsletter? *

Yes

No thanks

Messaging Consent

By providing your phone number, you agree to receive text messages from Metro-Detroit Mens Therapy. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.

Metro Detroit Area, MI
Contact: (248) 555-0198 | [email protected]

Licensed Professional Clinical Counselors · Specializing in Men's Mental Health