New Client Request Form(HIPAA compliant) Forma para clientes nuevas (se cumple con reglas de HIPAA)
Thank you for your interest in working with a therapist at Rose Wellness!
PLEASE NOTE- Our intake Admin is limited at this time, so it may take us a few days to get back to you. 

If you haven't heard back from us after a few days, please feel free to call our intake line at 805-394-8533 and leave us a voicemail.  Someone will get back to you as soon as we can. 

Thank you for your patience!

**IMPORTANT- We accept those that are privately paying for services.  if you are looking to go through your insurance please read the following information.

For working with an associate clinician (AMFT, ACSW, APCC) we are in network with 

Para trabajar con una terapeuta asociada somos contratados con los siguientes seguranzas:

  • Cigna
  • Cencal
  • Healthnet medi-cal (not MHN commercial), 
  • Anthem UCSHIP, 
  • Regular Anthem plans, 
  • Aetna, 
  • Cal Viva 
  • CA health and wellness.
For working with an LMFT or LCSW most clinicians are in network with :
Para trabajar con una terapeuta licensiada somos contratados con los siguientes seguranzas;
Your responses will be stored in our HIPAA compliant and private platform and reviewed by our intake specialists.  Please fill this form out in our entirety so that we can match you with the therapist that would be the best fit for you!
Sus respuestas estarán guardado en una sistema seguro y que cumple con reglas de HIPAA. Estaran revisados por nuestras especialistas de admisiónes.  A favor de llenar esta forma completamente para que podemos encontrar la terapeuta que se ajusta mejor para usted.
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Client's name 
Nombre del cliente
*
Preferred name of client if different from above
Nombre del cliente Preferido si es differente que arriba 

Client's pronouns (i.e. he, she, they, ze..etc)
Pronombres del cliente (ella, el..etc)
*
Client's DOB
Fecha de nacimiento del cliente
*
Age of client
Edad del cliente
Client's Email
Correo Electrónico del cliente
Client's Phone Number
Numero de telefono del cliente
*
Is it okay for us to leave a voicemail saying we are calling from Rose Wellness?
Esta bien si dejamos un mensaje de voz diciendo que somos de Rose Wellness?
*
COMMUNICATION *
Is it okay for us to send a text message to number above saying we are reaching out from Rose Wellness?  Or would you prefer we send you an encrypted email?
Esta bien que le contactemos por mensaje de texto diciendo que somos de Rose Wellness? O prefieres un correo electrónico codificado ?
What is the best time for us to reach you for a quick call (10 mins)
Cual es la hora mejor para contactarse para una llamada rápida (10 minutos)
*
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