Client Sign Up - Connect For Therapy, LLC - Free Referral to Therapist For Anxiety, Depression, Relationships, and Family Issues

Let Connect For Therapy Find a Licensed Therapist For You

Client Sign Up

Please fill out our form below. We will then contact you to review your information so that we can connect you to your new therapist.

Connect For Therapy will find you a professional based on the criteria you have given us. If you select face to face therapy, a professional in your area will contact you to set up an appointment. It's that simple.

There is one small caveat; if you participate in a HMO or any Federal health care program or state health insurance, which includes but is not limited to, medicare, medicaid, or Medi-CAL then we are unable to assist you in finding a therapist at this time. None of our therapists participate with those types of insurance.

Connect For Therapy does not provide crisis therapy. If you or someone you know is in a serious crisis situation, please call 911 immediately.

Referred by:
Email
Retype Email

Select Therapy Preference
	Face To Face		eTherapy		Telephone

Name: (first and last)
City:
State:
Zip:
Telephone:

Select Gender Preference For Therapist
	Male Therapist		Female Therapist		Either

Do You Have Health Insurance?
	Yes	No
If "yes" list type: e.g., Blue Cross, Aetna, United Behavioral, etc.

Check Problem(s) You Want To Address With Therapy:

	Abuse		Addiction
	Anger Management		Food/Diet
	Anxiety/Panic		Depression
	EMDR		Employment
	Family Issues		Sexuality
	Grief/Loss		Health
	Parenting		Hypnosis
	Life Transitions		Phobias/Fears
	Marriage Therapy		Couples Therapy
	PTSD		Stress Management
	Men's Issues		Women's Issues
	Personality Disorders		Relationships
	Self Esteem		Spirituality
	Dissociation		Other

Please give a summary of the problem you want help with. (Use as much space as you need.)

Connect For Therapy is also not intended for use by anyone under 18 years old. By submitting this form you are asserting that you are over 18 years old.
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