Blue Oak Online Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the form below, and we will contact you in one to two business days.

If you are currently experiencing a mental health crisis or emergency, please call 1(800) 273-8255 or 988 for crisis support or go to your nearest emergency room.

Email *

Blue Oak Therapy Center does not currently accept insurance, but can provide superbills (monthly statements that can be submitted to your insurance provider), which you can submit to your insurance company for possible reimbursement. Please contact your insurance directly to find out if you are eligible for reimbursement for out-of-network providers who are ACSWs, AMFTs, and APCCs.

Acknowledge

Required

Full Name: *

Age: *

Pronouns: *

Select all that apply

they/them

she/her

he/him

Other:

Required

What is your gender?: *

Example: Two-Spirit, Transgender, Woman, Genderqueer, Man, Non-binary, Gender non-conforming, Male, Female, Prefer not to say

What is your sexual identity/sexual orientation?: *

Example: Asexual, Bisexual, Lesbian, Gay, Queer, Straight, Pansexual, Aromantic, Questioning or unsure, Prefer not to say

Which category best describes you?: *

select all that apply

African

African-American/Black

Asian-American

East Asian (including Chinese, Japanese, Korean, Mongolian, Tibetan, and Taiwanese)

Hispanic

Latinx

Indigenous American/First Nations (including Native American/American Indian, Alaskan Native, Pacific Islander, and Native Hawaiian)

Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc.

South Asian (including Bangladeshi, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan)

Southeast Asian (including Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese)

White

Prefer not to say

Other:

Required

Phone Number: *

Email address: *

What is the best way to reach you?: *

Select all that apply

Phone

Text message

Required

If by phone, what are the best times to contact you?: *

Please specify time and day of the week (Example: Mon 5-6pm, Wed 2-4pm, Sat 9am-12pm). If not applicable, please write NA.

When we contact you, can we use our agency name in the message?: *

Yes

Are you currently a resident of California?: *

Yes

What type of therapy are you looking for?: *

Individual

Couples/relationship

Family

Child/teen

Clear form

Never submit passwords through Google Forms.

This form was created inside of Blue Oak Therapy Center.

Does this form look suspicious? Report

Forms