Referral Request

Referral Request

Please complete the following information. Someone will contact you as soon as we received the information. Thank you.

Name*

Cell Phone*

Email*

What type of treatment are you seeking?*

Psychoanalysis - a form of treatment that normally involves a longer duration of time (years) and at a frequency of usually 3 to 5 sessions per week.

Psychodynamic Psychotherapy usually involves one or two sessions per week, and may involve a duration of months or years.

Medication Management

Not Sure

Why are you seeking treatment? (one or two sentences)*

Please check your age group.*

Ages 3 to 12

Ages 12 to 18

Ages 19 to 25

Ages 25 to 35

Ages 45 to 55

Age 56+

Provider Preference

The information provided will help assist us with your request.

Specialty Interest*

Anxiety

Childhood

Depression

Dysregulation

Early Mother-Infant Trauma

Eating Disorders

Family Issues

Groups

Loss/Grief

Marriage

Parenting

Personality Disorders

Substance Addiction

Trauma

Session Preference*

In Person Session Only

Video Session Only

No Preference

Time Availability - please check all applicable*

Mornings

Afternoon

Evenings

Weekends Only

No restrictions

Geographic Area*

No Preference

Austin

San Antonio

Dallas

Houston - Downtown

Houston - Midtown

Houston - Northwest

Houston - Northeast

Houston - Southwest

Houston - Southeast

Other

List your general budget parameter and insurance carrier - please note that few on the listserv are in network with insurance*

How did you hear about us?*

Family

Friend

Mental Health Professional

Physician

Social Media

Other

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