ACIP Therapy Scholarship Application   - Part 2
We appreciate your interest in becoming a client at the Aguirre Center for Inclusive Psychotherapy and in our ACIP Therapy Scholarship Fund. Please take a few moments to help us learn more about what you are seeking. The information gathered on this form will be used to assess if our services may be a good fit for you and to match you with one of our therapists.   If we determine that we are not the best fit for your needs, we will provide you with referrals in the community.
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Full Name *
Email Address *
Date(s) of Birth *
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Phone Number *
What is your preferred method of being contacted? *
Required
How did you hear about Aguirre Center for Inclusive Psychotherapy?
Internet search,  Google Ads,  Online Therapist Directories (Latinx Therapy, Psychology Today, Therapy Den, Inclusive Therapists, etc). Social Media (Instagram, Facebook, etc)  or were you referred by another professional?
Reason For Seeking Services *
Please provide a brief description about the concerns you wish to address:
How would you like to receive our psychological services: *
Please indicate if you have a preferred therapist(s) to work with: *
Required
What is your availability for appointments? Specific days/times that are preferred? *
Do you currently struggle or have struggled with any of the following concerns: self-injurious behavior, compulsive sexual behaviors or porn addiction, an eating disorder, or chronic suicidality? *
If you are suicidal please go your nearest emergency room, call 911,  or contact  the  Georgia Crisis Line (800-714-4225) or the Crisis Text Line (text "START" to 741741).
Have you ever been hospitalized or received residential treatment for mental health  or substance abuse concerns? *
If yes, please share dates of treatment and focus of treatment.
Demographic Information: The following questions about Gender Identity and Sexual Orientation are completely OPTIONAL. We gather this information because some of our clinicians specialize working with working the LBTQIA+ community and this information helps us to match you with the right therapist (please refer to the clinician's individual bio's to learn more).
Gender Identity & Pronouns
Sexual Orientation/Identity
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