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Reduced Fee Psychotherapy for Current CSPP Students: Therapist Referral Information Form
Please note: Presently we are only able to accept licensed psychologists who live in the areas near one of our six CA campuses: Fresno, Irvine, Los Angeles, Sacramento, San Diego, San Francisco. Our San Diego campus additionally requires that you have been licensed at least three years.
Personal Information
First Name:
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Last Name:
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Gender:
Age:
Ethnicity:
Personal Disability Experience:
Contact Information
Business Address:
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Suite #:
City:
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State:
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Zip Code:
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Phone:
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Email:
*
Website:
Office Accessibility
Wheelchair Accessible Building:
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Yes
No
Accessible Office:
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Yes
No
Accessible Bathroom:
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Yes
No
Handicapped Parking:
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Yes
No
TTY Phone:
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Yes
No
Near Public Transit:
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Yes
No
Near Bus Stop:
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Yes
No
Education & Professional Training
Institution & Campus Attended for Highest Degree:
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Highest Degree:
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Year Degree Earned:
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Major Theoretical Orientation:
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Internship and Post-Doctoral Training Relative to Areas of Specialization:
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License Status (please check the appropriate status):
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Licensed Psychologist
Licensed Clinical Social Worker
Licensed MFT
Board Certified Psychiatrist
Board Eligible Psychologist
License Number:
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Date Issued:
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Date Expires:
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Professional Association Memberships (check all that apply):
APA
Asian American Psych Association
AB Psy
California Psych Association
California Association of Hispanic Psychologists
National Association of Social Workers
National Association of MFTs
Local Psych Association (e.g., SDPA, LACPA, SFPA)
other
Please Specify:
Therapy Experience and Preferences
Preferred Therapy Format:
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Individual
Couples
Family
Group
Assessment
Areas of Expertise:
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Populations Worked With:
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Languages Spoken:
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Have you ever had a mental health license suspended or revoked in this or any state? (If yes, please submit a written explanation in the space provided below):
*
Yes
No
Explanation:
Are you involved currently in any legal or ethical complaints about your practice? (If yes, please submit a written explanation in the space provided below):
*
Yes
No
Explanation:
Fee Structure:
Malpractice Insurance:
*
Amount of Coverage:
*
Normal Professional Fee Range:
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Student Minimum Fee Range:
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How Many Students Will You See At This Range:
*
Length of Guaranteed Minimum Range (list in months):
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Types of Insurance Accepted:
*
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