Anxiety and Trauma Clinic of Atlanta Referral Form
Hello! Thanks for your interest in services at the Anxiety and Trauma Clinic of Atlanta. We hope our services are a great fit for you, and that we can help you heal, recover, and grow, using effective psychotherapy.

Thanks for taking a little time to complete this form to help us understand your needs. This helps us make sure that we are the right place for you to seek therapy. Your responses will be recorded in a secure, HIPAA compliant form. Our team will carefully review this form and contact you by email.

Please also note that none of our clinicians see clients under the age of 16.

***This form should only be completed by people who are 18 years of age or older. If you are a minor, please work with a parent/legal guardian to complete this form.***
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Your name *
Are you filling out this form for yourself or another person?
 *
If you are filling this out for another person, what is the potential client's name?
How old is the potential client? *
What is your email address? *
What is your phone number? *
What state(s) will you reside in when therapy takes place? *
Please let us know, in a few sentences, the main thing(s) you are seeking therapy for right now. Have you been told, or suspect, that you have a particular diagnosis that you hope improves with the right therapy? Please also let us know what else you hope changes in your life if you found the right therapist for you. *
Please note that our clinic does not offer care for 1) active substance dependence, 2) autism spectrum disorders, 3) active or recent suicidal behavior or current intent to die, 4) current, ongoing self-harm behavior, 5) unmedicated bipolar disorder, 6) active psychosis, 7) recent violent behavior, or 8) evaluations intended to be used for legal purposes (e.g., child custody evaluations, PTSD evaluations for disability claims). *
Our clinicians typically only have availability during business hours (9-5, M-F), with each clinician having their own specific schedule. What is your availability? Are you able to schedule appointments during business hours? *
Our clinicians currently are working solely via telehealth/webcam. Research has shown that telehealth services are usually equally effective to in-person therapy, and often, we find that the therapies we offer are especially helpful when clients are in their home environments. Please check the box below if you understand and would like to pursue telehealth therapy with our clinic. *
Please note: We are not in-network with any insurance companies, and we do not bill insurance directly for any services. Clients pay us directly for care using credit cards or HSA/FSA cards (see the "Fees and Insurance" page of our website for our rates:  https://www.anxietytraumaclinic.com/fees-and-insurance). Note that our rates are reduced if you see a pre-licensed clinician at our practice, as indicated on this website. 

We offer receipts (called superbills) for clients with out-of-network benefits who wish to file for reimbursement. Please confirm that you understand and that you are able to pay out of pocket at this time.

**If you request an insurance-based provider, please note that we cannot guarantee that these providers have the same qualifications, expertise, and commitment to evidence-based care that we have. We also cannot be certain which insurance-based providers have current availability. However, we can send you a list of names of therapists that accept insurance in the area.
 *
Required
Please note which of the following clinicians you would like to see. Our website includes bios where you can find out more about each clinician. *
Required
We occasionally offer new services through our practice, such as group therapy options, workshops, and new providers with specialty expertise. Do you consent to add your email to our practice mailing list to stay up to date on this news? *
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