Blue Oak Online Intake Form
Please fill out the form below, and we will contact you in one to two business days.

If you are currently experiencing a mental health crisis or emergency, please call 1-800-273-8255 or 911 for crisis support or go to your nearest emergency room.

*Our low-fee therapy slots are currently full. Please check back later. We apologize for the impact this may have.
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Email *
Full Name *
Age *
Pronouns *
Select all that apply
What is your gender? *
Example: Two-Spirit, Transgender, Genderqueer, Non-binary, Gender non-conforming, Male, Female, Prefer not to say
What is your sexual identity/sexual orientation? *
Example: asexual, bisexual, lesbian, gay, queer, pansexual, aromantic, questioning or unsure, Prefer not to say
Which category best describes you? *
select all that apply
Phone Number *
Email address *
What is the best way to reach you? *
select all that apply
If by phone, what are the best times to contact you? *
Please specify time and day of the week (Example: Mon 5-6pm, Wed 2-4pm, Sat 9am-12pm). If not applicable please write NA
When we contact you, can we use our agency name in the message? *
Are you currently a resident of California? *
What type of therapy are you looking for? *
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