Therapy Inquiries CLICK SUBMIT AT THE END

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Client First Name *

(If child, would be child's first name, or if for couples, would be name of person whose insurance you are using)

Client Last Name *

(If child, would be child's last name, or if for couples, would be name of person whose insurance you are using)

Phone Number *

Do you prefer text or call and any certain time? (Example of Response: Either, Anytime) *

Email Address *

Adult, Child, Couples *

In-Person or Telehealth or Open *

Client DATE OF BIRTH *

YYYY

Insurance Company Name *

We accept almost ALL insurance plans including Medi-Cal and Medicare even more than are listed on the website as it is always growing. We DO NOT accept CHG.

Insurance Member ID or Social Security

If Military - this is the number listed on the back of ID card labeled Benefits Number not your DOD number

Availability of Appointment Days and Times Monday to Thursday 6a to 5:30p *

Any other information you want to add including Language, Treatment Approach (ex, ERP or EMDR) or Culture or Therapist please type below *

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Yes

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