Washtenaw Psychology Society

Referral Request Form

If you are looking for a psychologist in the Washtenaw County area, we are here to help. Please fill out this form so we have a better idea of the client's needs and one or more of our members who have availability will contact you.

Disclaimer

WPS provides your information to WPS member psychologists.
WPS does not endorse or rate any of the psychologists in our member directory.
WPS does not guarantee that you will find a therapist through WPS.
WPS does not make a determination as to whether a particular psychologist is appropriate for you.
WPS does not make your information public. However, this form is not HIPAA-secured. Please do not divulge personally identifiable information.

First Name *

Last Name *

Email *

What is a good contact email?

10 Digit Contact Phone Number * min: 2147483647

What is the contact relationship with the potential patient?
Eg: parent/guardian, spouse, sibling, friend, employer, other healthcare provider... etc. *

What age range does the patient fall within?
Choose 1

What kind of issues is the patient hoping to address with therapy? *

(Word limit: 300)

What type of treatment is the patient seeking?
Eg: CBT, Exposure Therapy, Psychodynamic Therapy, Interpersonal Therapy, Trauma Focused Therapy... etc.

Which insurance does the patient carry, if any.
Eg: Blue Cross PPO, Blue Care Network (BCN), Medicare, Medicaid... etc.

Is self-pay an option? *

Yes

Patient Gender

Is the patient seeking telehealth or in-person therapy?
Choose 1

Note patient's availability (Days/times you are free)

Does the patient prefer a specific gender of therapist? If so, please describe.

How did you hear about Washtenaw Psychology Society?