Wave Therapy - New Client Form

Thank you for reaching out to us at Wave Therapy! WAVE stands for WISDOM, ACTION, VULNERABILITY, and ENCOURAGEMENT.

To begin connecting you with a therapist in our practice, please complete this form. We are committed to your privacy. All client information shared directly with our team is stored in our HIPAA compliant servers.


To speak with a team member, call our mainline at (760) 500-3325.

Once insurance is verified you will receive an email with instructions on how to Book your assessment with a Clinical Liaison and Fill out the Intake Paperwork. 

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In the event that you or a loved one are feeling unsafe or requires immediate medical or psychiatric assistance, call 911 or go to the nearest emergency room or call the Crisis Assessment Team at 1-866-830-6011 or 714-517-6353. Call the San Diego County Access and Crisis Line at 1-888-724-7240, or the Suicide and Crisis Lifeline at 988.

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Email *
Please provide your name as the primary contact *
Please provide your best contact number
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For clients over the age of 16 (excluding yourself), please provide the following contact information:

Client Name

Client Email

Client Contact #

Due to HIPAA regulations, if a prospective client is 18 years or older, we cannot provide updates to other parties without the necessary documented consent.

Client Details:

Please list the legal names of each prospective client
Client(s) Name (as shown on Insurance card):
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Client's Date of Birth:

If multiple clients, please write in as follows: 

Jane: 1/23/2000, John: 2/22/2002

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Client's Legal Gender (please fill in for each prospective client)

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Client's Gender Identity (please fill in for each prospective client)

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Client Details:

To ensure our sessions are as helpful and comfortable as possible, are there any physical or sensory accommodations our clinicians should be aware of, or anything about the office setup we need to adjust for you?

Client Details:

Current Residence Address (STREET ADDRESS, CITY, STATE, ZIP CODE)

Note: If the address for a prospective client is different from the current residence address listed above, please provide the specific address for that client.

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How did you hear about Wave Therapy? 

What types of services you are seeking (Individual, Couples, or Family)?

Please provide a brief description of your reason for seeking counseling (i.e., anxiety, PTSD, depression, etc.)

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Would you prefer in-person or virtual appointments? 
*Please note, we have limited availability for in-person at this time.
Clear selection

Which office location do you prefer? 

Please select all that apply. Please also select a backup option in case your preferred location is limited/unavailable.

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Required

What are some days/times you are available for appointments?

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Do you have any preference for a male or female therapist, or are you open to either? 

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Requested Provider: (if any) *Not guaranteed as our therapist are not all accepting new clients nor accept all insurances.

*Please indicate if you are already in contact with a clinician on our team.

*If no requested provider, please write "N/A"

What is your primary language? 

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Are these services court-ordered? Please note, Wave is unable to provide court-ordered documentation.

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Are you currently working with another provider or agency?

If yes, please write in name of provider/agency in "other" 

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Are you a current or former client at Wave Therapy? 

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Services for Minors (If Applies):

Are these services for a minor? 

*Please be advised, if you are trying to set up your minor child for counseling services, we will need any required custody documents, if applicable, prior to the client being seen for an appointment at Wave Therapy. 

**If more than one parent needs to provide consent, we require written consent prior to any appointments. 

***If you are the guardian or acting guardian, please provide paperwork to confirm guardianship.

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Services for Minors (If Applies):

Is there shared custody? 

**If a custody agreement applies, please inform us and attach a copy if available.

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Services for Minors (If Applies):

Do both parents need to consent for therapy? 
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Services for Minors (If Applies):

If both parents need to consent for therapy, please provide: 

Parent 2 Name

Parent 2 Phone #

Parent 2 Email

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Insurance Information:

Name of Primary Insurance
*If you anticipate any changes to your insurance on January 1st, please notify our office. This helps us ensure your billing is accurate.

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Insurance Information:

Primary Insurance: 
ID Number & GROUP Number (if applies)

*For TRICARE, if you are a dependent, please provide your sponsor's Social Security Number (SSN). If you prefer not to include this information on the form, please call us at (760) 500-3325.
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Insurance Information:

Subscriber Name:

Subscriber DOB:

Relationship to Subscriber: (Self, spouse, child, other)

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Insurance Information: 

Do you have more than one insurance? (Including any type of Medi-Cal or Medicare, such as Community Health Group (CHG) or Blue Shield Promise): 

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Email a photo of the FRONT and BACK of your insurance card to insurance@wave-therapist.org. Sending this helps avoid any billing issues.

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