Secure Contact Form for Authentic Alliance

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Thanks for taking the time to provide us a little more information to prepare our provider to meet with you.

If a question does not apply to you, type or mark 0 or N/A

Email *

Your Name (Chosen or Legal) *

Our charts and paperwork default to your legal name in an effort to protect your privacy. Your therapist will follow up on with you on this when you meet with them.

Pronoun

Phone Number *

Date of Birth (if you are seeking therapy)

SCHEDULING FOR YOUR TEEN/CHILD--please let us know their (1) legal and (2) chosen name, (3)pronouns and (4) date of birth(5) email (5) phone number

Best Method of Contact? *

Text (please make sure you are OK with any previews of texts that we may send you)

Phone (which may include leaving a voicemail)

Other:

Required

What State Do You Live In? *

Have you already booked a 15 min intro appt?

Yes

Other:

Clear selection

If you don't already have an appointment, you can book a free 15 min intro meeting here https://authentic-alliance.clientsecure.me/request/clinician.

NOT SURE WHICH THERAPIST YOU WANT? No problem, the job of our Client Care Coordinator is to help determine fit and makes sure your schedule and needs match with your therapist's. Submit this form and they can contact you to talk about which therapist is best, before booking you an into 15 min intro meeting.

What Service Are You Seeking? *

Psychotherapy

Group Therapy: Authentic Alliance Gender Group

Group Therapy: Building Collective Resilience

Gender Health Evaluation or a Referral Letter for a Doctor

Mental Health Provider/Therapist: WPATH Mentor Interest (Go here:https://www.authentic-alliance.com/wpath-certification)

Therapists: Consultation (Go here: https://www.authentic-alliance.com/consultation)

Contact Our Staff or Client Coordinator with a Question

Other:

Required

What is your preference for day of the week, time and frequency of when you would like to have your appointments? Example, "I want to see my therapist on Mondays after 4pm every week." *

Language other than English Preferred/Needed?

Are you wanting telehealth (video or phone therapy)? *

Yes

Are you wanting in-person therapy?

In our Oakland office

In our San Francisco office in the downtown shopping district area

Hybrid Option (telehealth and in-person in San Francico)

Hybrid Option (telehealth and in-person in Oakland

Clear selection

Payment/Insurance You Are Using?

Note: the first three on this list are the only IN NETWORK plans we take

Optum, United Behavioral Health/UBH, UnitedHealthcare/UHC)

Lyra Health

CCA

PPO plan with Out-Of-Network Benefits

Self Pay/Out-of-Pocket

Other:

What type of first meeting would you like?

First Intake Session with a Therapist (50 min)

15 min free introductory meeting, which is not a therapy session

Consultation Meeting (for Therapists Only)

Not sure, I want to ask the Client Coordinator which would be best

Other:

Clear selection

Briefly share what topics you'd like to focus on.
*

CHECK IN QUESTIONS--One of our therapists may reach out to you if your answers below concern us. If you are in crisis, please consider calling 988 or going to an emergency room for help as we cannot guarantee a timely response. Visit our websites's crisis page for hotlines.

How often do you have thoughts of wanting to harm or kill yourself? *

Not at all

Constantly

How often do you have thoughts of wanting to harm (without consent) or kill another person? *

Not at all

Constantly

This is a difficult question but do the best you can...If you answered that you have these thoughts...How likely do you think it is that you will *actually* harm yourself or another person? *

Not likely at all

I will do it

When you think about your use of substances (drugs and alcohol), do you feel your use is problematic? *

Not at all an issue

Absolutely, its the main reason I need therapy

Is there a specific team member that you would like to work with? *

Sage Barrett, ASW

Anthony Magnia, AMFT, APCC

Lisette Lahana, LCSW

Bridget Bertrand, LMFT

Need help choosing my therapist

No preference

Other:

Required

Do you have any questions for our team? Here is our team list.

How did you hear about us? *

If you marked Other or a specific provider/doctor, please let us know their name (optional).

Thanks for contacting us. Based on your answers our staff may need to follow up with you today or within 3 business days.

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