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

Contact Information

Office Accessibility

* Wheelchair Accessible Building:
* Accessible Office:
* Accessible Bathroom:
* Handicapped Parking:
* TTY Phone:
* Near Public Transit:
* Near Bus Stop:

Education & Professional Training

* License Status (please check the appropriate status):
Professional Association Memberships (check all that apply):

Therapy Experience and Preferences

* Preferred Therapy Format:
* 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):
* 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):

Fee Structure:

* Indicates Response Required