Request for help finding a therapist

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you are in crisis or think you have an emergency, call your doctor or 911 immediately. If you're having suicidal thoughts, call 1-800-273-TALK (8255) to talk to a skilled, trained counselor at a crisis center in your area at any time (National Suicide Prevention Lifeline). If you are located outside the United States, call your local emergency line immediately.

Email *

Your First and Last Name

Who is this therapist for

Yourself

Child

Friend

Other

Clear selection

Age of the person that would be seeing the therapist

What is the main reason for seeing a therapist?

What town do you live in? (There is no requirement that you live in Pelham to use this referral service - information is to help locate a therapist nearby.)

Preference of the gender

Female

Male

I have no preference

Clear selection

Would you like to use insurance?

Yes

Maybe

Clear selection

If you would like to use insurance, what insurance are you using?

Any certain ethnic or religious identity of the provider? If so please specify.

Is there anything else you'd like me to know about your preferences in choosing a provider?

Phone number (optional)

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms