Welcome to Sycamore Grove 

We’re so glad you’re here.

This form will help us understand your needs and connect you with a therapist who is a good fit. Please answer the questions openly and honestly. Your responses are kept confidential except in circumstances outlined by state and federal law.

After you submit the form, you will receive a call from the therapist best suited to meet your needs, usually within two business days, to schedule a session. Depending on your responses to this intake form, we may contact you before connecting you with a therapist.

If you have any questions, concerns, or a specific request, please reach out to our office at welcome@sycamoregrove.org or (925) 820-1467.

Thank you for taking the time to fill out this form. We look forward to supporting you.

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Email *
Please be aware: We are not a crisis center. If you are in immediate danger please call 911. Other crisis resources are 988 and (800) 273-8255.

What is your full name? *
Please provide the full name each participant.  *
Please provide the date of birth for each participant.  *
What is the best phone number to reach you?
If you're contacting us for a minor, please include cell phone numbers for all legal guardians. For couples or family counseling, please provide a cell phone number for each adult participant. *
What is the best email address to reach you?
If you're contacting us for a minor, please include all legal guardian email addresses. For couples or family counseling, please provide email addresses for each adult participant. *
For a minor, is there a custody agreement (including separation)? *
Required
For a minor with a custody agreement, please fill in legal guardian information including name, email and phone number for each legal guardian.
What is your (or the participant’s) physical address?
 *
What are your (or the participant's) reasons for seeking therapy at this time? 
Please share in 2-3 sentences.

 *
What are the best times of day for you (or for the participant) to meet with a therapist?
Please list the days of the week and time ranges that work best.
 *
If you have been referred to or would like to request a specific therapist, please provide their name below. While we cannot guarantee their availability, if they do have openings, they will be the one to contact you.
Do you have any concerns about eating or nutrition for yourself (or the participant)?
 *
Are you (or the participant) experiencing self-harm or suicidal thoughts?
 *
Our standard fee ranges from $105 to $225 per 50-minute session, depending on the therapist’s licensing and certification. 
If you prefer to be placed with a lower fee therapist, please let us know and we will do our best to accommodate your request.   *
Please note that we are out of network with all insurance providers. If you plan to use your insurance benefits, we recommend contacting your insurance company directly to understand your out-of-network coverage options. Please also confirm with CPCC, prior to your first session, that we are capable of providing the required information to help you make the most of your benefits. *
Required
Do you prefer in-person or video sessions?
 *
How did you hear about us? *
Is there anything else you'd like us to know?
Consent to Contact and Share Information
By submitting this form, I give permission for Sycamore Grove to contact me using the phone number and/or email provided. I understand that this information will be used solely for the purpose of scheduling services and coordinating care.   *
Required
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