Contact

Make a Referral

If you are a provider who would like to refer one of your clients, please either give us a call, fax us a referral order, send us an email, or fill out the form to the left. Please include as many details as you can.

Of note, we can only provide psychotherapy to adults. Psychological evaluations are available for individuals ages 8 through 55. We are not currently accepting new referrals for psychotherapy.

Client's Legal Name

First Name

Last Name

Client's Preferred Name

First Name

Last Name

Client's Pronouns

Client's Gender Identity

Client's Assigned Sex at Birth

Client's Age

must be between the ages of 8-55 for testing; 18+ for psychotherapy

Parent/ Guardian #1 Name

First Name

Last Name

Parent/ Guardian #2 Name

First Name

Last Name

Parent/ Guardian #3 Name

First Name

Last Name

Parent/ Guardian #4 Name

First Name

Last Name

Client's Email

best email to reach the Client (if they are 18 or older) or the parent/ guardian

Client's Address (if you don't have their email, this is required)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Phone

Best number to reach the Client (if they are 18 or older) or the parent/ guardian

(###)

###

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Insurance

What insurance does your client have?

Reason for Referral (required)

Provide a brief description of why you are seeking our services for your client.

What services are you recommending?

Psychotherapy (w/ Dr. Gillian Woldorf) - Not currently accepting new therapy clients

Psychological Assessment

Preference

If recommending a psychological assessment, do you have a preference who they see?

Your Name

First Name

Last Name

Your Relationship to the Client

Your Email

Your Phone Number

(###)

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Make a Referral

Location

Hours