Queer Humboldt Therapy Referral Form

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Queer Humboldt offers mental health services for LGBTQ community members and the loving adults of queer youth. If you are interested in learning more about our services, please fill out the below referral form and someone from our organization will get back to you with more information.

Please know we will reach out to the contact information provided below and we will leave voicemails/emails with our agency name and that we are responding to your referral.

Name *

Pronouns (optional)

Client birthday(s) *

Email *

Address (including city) *

Phone number *

This inquiry is for (check as many as you are interested in): *

Individual Therapy

Couples Therapy

Family Therapy

Interested in Group Therapy

Other:

Required

Check any that apply: *

Client identifies as queer/LGBTQ2+

Client is a caregiver of a queer and/or gender expansive youth

Client is under 18 years old

Other:

Required

Would you be interested in participating in group therapy in the future? If so, please check what groups may be of interest to you.

Gender Expansive/Trans/non binary support group

Youth social groups

Elder Support group (50ish and over)

Domestic Abuse Survivors Support and Healing Group

Disordered Eating Support and Healing Group

Anxiety and Depression Support and Skills Group

Neurodivergent Support and Skills Group

Healing From Hate Support Group

Please share a few words about why you are seeking therapy services at this time: *

Is there anything else you would like us to know before contacting you? *

Thank you for your interest. We will reach out to your contact information as soon as we are able.

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