Application for Intensive Referral Program
Print, complete and return this questionnaire with a $300.00 deposit and a photocopy of your photo ID (passport, driver’s license, ID card) to:
3428 Motor Avenue
Los Angeles, CA 90034
Please make checks payable to IPSA Intensives Referral.
Mailing Address (if different):
Phone: Day- Evening-
Best times to reach you by phone:
Problem you wish to address in surrogate partner therapy:
Your goals regarding this therapy:
Describe any special circumstances we should know about:
Are you Currently in Therapy? YES NO
Therapist name and phone number (recommended):
Please give a brief history of your therapy experience(s), if any.
Have you ever been married? YES NO
Please describe you current relationship situation :
Currently employed? YES NO
Type of employment:
When would you like the intensive therapy to begin?
Are you able to travel to California? YES NO
Do you prefer a California Intensive or an Intensive in your home area?
Length of program you are considering? 1-week 10-days 2-weeks other
As a courtesy to traveling clients, upon request IPSA will provide a list of clean, safe, and modest options and conveniently located for lodgings. If you wish luxury accommodations, please indicate the price range you would find acceptable: .
Please list any special requirements you have:
How did you learn about IPSA?