Request an Appointment
Tell us more about you and what you're looking for in your care. We'll review the information you provide and a Foresight Enrollment Specialist will reach out to you with next steps within 5 business days.

By filling out this form, you understand that Foresight may book you automatically for a series of weekly recurring appointments based on the information you have provided below.   


**Please note that for the time being, all of our appointments are telehealth only.**
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Full legal name of the person seeking care *
Email Address *
Parent or legal guardian full name (If this appointment is for someone under the age of 18, please provide this information)
Phone Number *
Date of birth for person seeking care *
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What Is your street address? (ex. 123 Main St) *
What city do you reside in? *
What state do you reside in? 
We're currently only offering services in the states listed below.
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What is your zip code? *
What is your billing address? Please include city, state, and zip code.   *
Gender (As listed on insurance) *
What type of care are you seeking? *
Who is Your Insurance Carrier?

(To confirm your share of cost, we recommend that you reach out to your insurance carrier)
*
What is your Insurance/Subscriber ID number?  *
If you have Kaiser, Beacon, SHIP, EAP benefits, or another insurance that requires authorization information, please specify which carrier and enter the authorization number, start date, and end date here. If you do not have one of these insurances, please type none. 

**If you have UC SHIP, please specify which university you're attending.**
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Name of primary subscriber *
DOB of primary subscriber *
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Your preferences (Do you have any preferences regarding your provider's age, gender, race/ethnicity, language spoken, etc.?)
Please enter the day(s) and times would you prefer to have your appointment scheduled?

These are the dates and times that we will be using to auto-book your appointments Please be as specific as possible with the times you are able to be booked
*
What are the best days or times of day to contact you? Please note all times are in PST *
Required
Care needed (Are there any specialties/areas of expertise your ideal provider should work with? Any modalities/types or methods of therapy they should be able to offer?)
Anything else you'd like to share with us?

If you have requested family or couples therapy, please include the name, DOB, phone number, email address, and physical address (if different) for all participants. 
Is there a specific provider you would like to see? If so, please list their name(s) here.  If the Provider that you listed is unavailable, are you open to other providers that meet the same criteria?
We'd like to be able to text you about your request to more easily assist you. If you prefer to not receive text messages, please let us know below. *
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