Referral Form

Name *

First Name

Last Name

Phone *

(###)

###

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What state are you located in? *

Please be aware we are only able to serve clients located in Louisiana and Texas at this time.

Louisiana

Texas

Please select your reason(s) for seeking services at this time. *

If you are actively experiencing suicidal thoughts or suicidal ideation, please dial 911 and/or report to your nearest emergency room.

Anxiety

Depression or mood changes

Relationship issues

Trauma

Parenting issues

Grief

Family issues

Anger

Personality changes

Career related stress

Self-harm

Adjusting to life transitions

Are you interested in telehealth or in person sessions? *

Telehealth

In-person (Monroe, LA office)