Let’s work togetherPlease complete this quick form to be added to my referral resources. Name * First Name Last Name Email * Phone (###) ### #### Website http:// Are you accepting new clients? YES NO IT DEPENDS ON THE CLIENT'S PRIMARY CONCERN What types of clients are you MOST interested in working with? Kids Teens Adults Older Adults/Seniors Families Couples Indigenous Clients Immigrants/Refugees LGBTQ2IA+ Clients Non-Binary/Trans Clients Women Men Other Please list the conditions/issues you specialize in. Please list the theories/modalities/interventions you work with. What formats do you offer? In-person Virtual Telephone In nature Group Workshops Retreat Other Do you provide options for low income clientele? YES NO IT DEPENDS ON THE CIRCUMSTANCES OF THE CLIENT Do you offer supervision to interns or colleagues? YES NO Is there anything specific you want me to know about your practice? Thank you for joining my resource network of therapists and other mental health specialists. I look forward to connecting you with potential clients. Please reach out if you have any further questions, and please feel free to forward this form to any colleagues who might benefit from new referrals.
