Intensive Therapy Application

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:

3679 Motor Avenue, Suite 205
Los Angeles, CA 90034

Please make checks payable to IPSA Intensives Referral.


Name:                                                                     Age:

Street Address:


Zip Code:

Mailing Address (if different):


Day Phone –

Evening Phone –

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:

Educational background:

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?