Appointment Request Form

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Salam Alaykum. Thank you for choosing Maristan.

Please ensure to complete this form using the personal information for the individual seeking services. If you are filling out this form on behalf of someone else, please ensure you use their personal information.

Note: This form is confidential and will only be viewed by members of the Maristan clinic to support scheduling.

* Please note that in addition to conducting sessions virtually, Maristan has an office space at MCC where we are now conducting in-person sessions. Address: 5724 W Las Positas Blvd #300, Pleasanton, CA 94588

Who are you seeking services for today? *

*Note: Due to state regulations, individuals are only able to submit a form for themselves or those whom they have legal guardianship over.

Myself

My child (under the age of 18)

Other:

Full Name *

Sex

Male

Female

Clear selection

Full Address (please include city, state and zip code) *

Phone number *

Can we leave a voicemail? *

Yes

Date of Birth *

YYYY

Email *

Are you currently a California resident?

*Note: Due to state regulations mandating the practice of mental health we are unable to offer therapy sessions to residents outside the state of California.

Yes

Clear selection

What service are you seeking? *

*Note: For couples or family therapy, each individual will need to submit an appointment request form. For minors, legal guardians may fill out their form using their personal information.

Individual Therapy

Couples Therapy

Family Therapy

Other:

If seeking couples or family therapy, please provide the name of each individual you will be in session with

Reason for service:

Please be as specific as possible so that we can match you with the clinician best suited for your needs

Prescreening Call
A member of Maristan's clinical team will give you a call to begin the scheduling process and ask a few questions regarding your mental health history. Please note that these calls are completely confidential.

Please select all times that work for you. If none of these time work, a member of out team will reach out to find a suitable time.

Tuesday between 10am and 2pm PST

Thursday between 11am and 3pm PST

None of these times work

Are you seeking virtual or in-person services? *

*Please note that Maristan's private office space is located at MCC East Bay, 5724 W Las Positas Blvd #300, Pleasanton, CA 94588

Virtual

In-person

Preferred Clinician: *

Please visit maristan.org to learn more about our clinicians.

*Please note that Dr. Rania Awaad does not see clients at Maristan

**Please also note that Brother Hamed and Dr. Sadiya are unable to see any insurance clients at this time.

Hamed Fatahian, LMFT

Saha Jamshed, LCSW

Nuzhath Quadri, LMFT

Tephiny Jones ACSW

First Available

Other:

Are you a recipient of the ARSI grant?

Yes

Clear selection

Comments:

Submit

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