Patient Profile and Request for referral

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After you fill out this request for wellness support, we will contact you to go over details and availability before a referral is made. Completing this form completely will give us the best opportunity to connect you with a good provider. For additional information on this referral process or to follow up on your request, please email us at office@pppassociates.com.

What type of support are you looking for? *

Therapist/Counselor

Medication evaluation and/or treatment

Assistance with community resources

Evaluation/Psychological Testing

Support Group

Other

Please describe the person who is needing assistance. *

Please enter the product number

Adult

Child (Age 0-12)

Elderly Adult (Ages 65+)

Adolescent (Age 13-18)

A couple

A family

Required

Type of service requested?

In person

Telehealth/Video

Both/Either can work

What modality of treatment are you looking for?

Individual

Couples

Family (Parent/Child; Siblings; Mutigenerational)

Group

Clear selection

What characteristics of provider do you prefer?

Male

Female

Faith-based - Christian

Faith-based - Buddhist

Faith-based - Muslim

Faith-based - Other

LGBTQ experience

Please describe the problem you are seeking assistance for.

Please also mark all of the current problems you are seeking help and support for. *

Depression/Sadness/Loneliness (Mood)

Anxiety/Panic/Fear

Substance use related problems

Problems with childhood behaviors/learning (Developmental)

Problems with perception/reality/unusual experiences

Family Relationships and/or Couples Problems

Addictions other than substance use (eg. eating, sexual behaviors)

Parenting concerns

Problems with pregnancy or post-partum complications (Maternal)

Education/Vocational/Career Development

Early childhood trauma/abuse/neglect (Complex)

Race-based Trauma/Abuse/Discrimination/Aggression

Performance development and/or Exercise Psychology

Other:

Required

In what ways are you hoping to develop?

Change in my behaviors

Managing my emotions

Improve my relationships

Make progress toward personal goals

Learn new skills (ie: conflict resolution; problem solving; communication)

Something else

What is your method of payment for the service?

Private pay

Insurance

Currently unable to pay for services

Other

Clear selection

If you do not have insurance to help pay for the service, what amount are you able to pay per visit for the services?

If you have insurance, please provide the name of the carrier.

Please -provide your insurance member ID number

Full name of person seeking services

Date of Birth the person seeking services (MM/DD/YYYY) *

Phone number *

E-mail *

Preferred contact method *

Phone

Required

How did you learn about this network?

Submit

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