Referral Form
Referral affiliates of PPC and PPC members. Please do not include identifying information as this service is not confidential.
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Email *
Name, Credentials, Location *
Email Subject Line *
Age, gender of client, brief problem statement, location, insurance, therapist characteristics
Insurance/Private Pay Capability *
Required
Contact method *
Scheduling needs (day, time, frequency) *
Clinician characteristics (gender, age, discipline, theory base, race, etc.) *
Type of Service *
Required
Nature of problem *
Submit
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