Therapy Request Form

This form is used to collect basic referral information for individuals seeking therapy services. All submitted information will be reviewed and entered into our internal system to create or update a client profile.

Please note that submission of this form does not confirm immediate placement. Our Administrative Assistant conducts outreach to referred individuals every Tuesday and Wednesday to complete intake, determine appropriate placement, and coordinate future scheduling.

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Would you prefer a Male or Female Therapist? *
Preferred day of the week?  *
Required
Preferred time of day? (Each session is 1 hour) *
Required
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