Counseling and Coaching Referral Service (Courtesy of Dr. Thompson)

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Finding the right therapist can feel overwhelming. This form will help me gather information so I can provide you with possible referral options to qualified professionals in your area. I’ll review your responses and follow up within 48 hours.

Disclaimer:
This referral concierge service is not a substitute for therapy or emergency care. It is an informational service only, intended to connect you with potential therapists who may fit your needs. No guarantee is made regarding availability, suitability, or outcomes. If you are in crisis or feel unsafe, please call 988 right away or go to your nearest emergency room.
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Please enter a valid phone number.
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How Soon Do You Need An Appointment?* This field is required.
Date
Year
Month
Day
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Are you open to telehealth/online therapy?
yes
no
maybe
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Your Needs* This field is required.Main Concern (check all that apply)
Betrayal Trauma / Infidelity Recovery
Anxiety
Depression
Relationship Counseling
Other (short answer)
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I prefer* This field is required.
Counseling
Coaching
A Combination of Counseling and Coaching
Unsure
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Urgency & Insurance* This field is required.How soon would you like to start?
Within 1 week
Within 2–3 weeks
Flexible
I need something today
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Insurance or Self-Pay?* This field is required.
Insurance only
Self Pay
Flexible
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What benefit do you need to use* This field is required.Ex. Aetna, United, Blue Cross Blue Shield, Cigna
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SMS Marketing Opt-In -* This field is required.
yes
no
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Anything else you’d like me to know?(Optional)
Huge
Large
Normal
Small
Ok
Ok
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Signature* This field is required.Disclaimer & Acknowledgment Please review the following before submitting: This referral concierge service is not therapy or medical treatment. Completing this form and receiving referral information does not establish a therapist–client relationship with Dr. Monique Thompson. No guarantee is made regarding the availability, suitability, or outcome of any provider referred. All providers are independent practitioners. Dr. Thompson does not supervise or accept liability for their services. While your information will be kept private to the best of my ability, please note that electronic communication is not 100% secure. Limit highly sensitive details. This service is intended for individuals located in the United States. Referral options outside the U.S. may be limited. Any educational resources shared (books, guides, workshops) are for informational purposes only and are not a substitute for therapy. If you are in crisis or feel unsafe, call 911 or go to your nearest emergency room
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Choose How You Would Like To Move Forward* This field is required.
Get my referral list (within 48 hours)
Schedule with Dr. Thompson
Get my referrals and explore scheduling with Dr. Thompson
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