Psychotherapy Referral Form Name * First Name Last Name Email * Phone * (###) ### #### 1) What type and frequency of services are you requesting? Do you have any preferences in type of therapy or therapist? * 2) What is your availability? Do you have a preference for office based or telehealth services? * 3) Please list any behavioral health services you have received in the past including diagnoses and medications. * 4) Are you experiencing suicidal/homicidal ideation currently or in the past? * 5) Do you have insurance you would like to use? Are you open to sliding scale instead? * 6) Are you seeking any type of assistance with community supports or referrals? * 7) Are there any aspects of your identity, health, living or situational status that you think are important for us to know? * Thank you!