Contact Us

Client Date of Birth *

Insurance Phone Number:

Phone Number: *

Prefer a male or female therapist: *

Email: *

In person or Virtual Appointments Preferred: *

Name: *

Issues / Concerns / Questions *

Potential client name if different than above:

23965 Novi Rd. Suite 110 Novi MI 48375 US

Phone: (248) 344-7420
Fax: (248) 344-7423

Email: northbrookclinic@sbcglobal.net

Preferred Appointment Time: *

Policy Holders Name and DOB:

Insurance Company: *

Northbrook Psychological Clinic

Member ID/Contract Number:

Monday-Thursday: 8:30am-9pm

Friday: 8:30am- 6pm

Saturday: By Appointment