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: