First Name *

Last Name *

Email *

Phone *

License #

Practice Location (or online) *

Practice Name - if applicable

Website

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The Basics *

Accepting new clients? Y/N. Accept Insurance (if yes, list carriers). Describe your: Session fee/rate, Is there a free consultation? Do you offer virtual sessions, in person only, both?

Any professional references you wish to add.

Personal Statement: Perhaps answer "why are you a therapist?" or "What do you love about MI?"

Clinical Services Provided (be concise)

Therapeutic Approach

Credentials

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We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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The Value of Membership

Michigan Therapists Professional Membership