Therapyrequest

Request a Therapist

Free Mental Healthcare

If you are having a psychiatric or medical emergency do not fill out this form. Please call 911 or go to your nearest hospital.

* Indicates required field

Name (Chosen) *

First

Last

Pronouns *

Email *

Phone Number *

Therapy Method *

In Person (Riverside County) Telehealth (Video) Telehealth (Phone)

Services Needed *

Ongoing Therapy (More Than 10 Sessions) Short Term Therapy (Up to 10 Sessions) Crisis Intervention Gender Affirmation Letter Connection to Psychiatry

Comments? *

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