Psychological Service Request Form

Welcome to KPA's Psychological Services Request Form! Here are a few things you should know before making your request.

1. Information you submit in this form will be deidentified and sent out via an email to the KPA membership base. If a KPA member responds and can provide the services you are seeking the KPA Central Office Staff will notify you via email with the responders contact information.

2. KPA cannot guarantee that we will find a provider for you. If you do not receive an email from us with referral information we have not received a response to your request.

Name (this will not be shared with our membership database): *

First NameLast Name

Email - please use an email address you have regular access to as this is where we'll send any responses we receive. *

example@example.com

Phone Number

Please enter a valid phone number.

Are you open to telehealth?*

YesNo

Would you prefer services that are:

Telehealth onlyA mix of in person and telehealth

Distance you are willing to travel?*

Age group of person in need of services:*

0 - 5 years of age5 - 12 years of age13 - 18 years of age18 years +

Please indicate what insurance you would like to use, if applicable:

Are you open to a provider who does not accept insurance?*

YesNo

Please tell us a little about what you are seeking services for:*