Appointment Request Form
Thank you for contacting us!  Please provide the following information so that we can best assist you.
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Name *
Email *
May we contact you using this email? *
Phone *
May we leave a message at this phone number? *
Insurance *
Are you a MediCal member? *
Are you a MediCare member? *
Are you seeking services through the Family Culture Coaching Alliance with Yes2Kollege Educational Resources, Inc.? *
How did you hear about The Rosetta Center?
Tell us briefly what you are seeking support for.  Please note: we do not take custody cases, active legal cases (except Victim Witness), or workers compensation cases. *
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