Intake Screener - Anxiety Therapy LA
Date *
MM
/
DD
/
YYYY
Name *
Best phone number to reach you or client *
XXX-XXX-XXXX
Email Address *
Calling for:
Clear selection
Name of client if not calling for self
Client age *
Client location
Preferred office location *
This is for after the shelter in place is lifted and it's safe to go into the office.
Primary condition *
Required
Previous Therapy
Clear selection
Primarily interested in: *
Please note at this time we are only providing online therapy until it is safe to meet in person.
Therapist preference: *
We have 5 therapists who work at Anxiety Therapy LA. For more information about our therapists please see https://anxietytherapyla.com/meet-our-team.
Preferred day of the week (Check all that apply) *
Required
Preferred time of day (Check all that apply) *
Required
How did you hear about us?
Please note, we are out of network with all insurance companies. We can provide a superbill for you to get reimbursement from your insurance company. Payment is required at time of treatment. *
Required
I allow Anxiety Therapy LA to contact me via email or phone to connect about possible treatment. We will respond within 48 hours. Please make sure to check your spam folder if you have not heard from us. *
Required
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