Blue Oak Counseling Contact Form

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Please fill out this form for online therapy and our client care coordinator will contact you during our business hours. Please allow 24-48 hours for a response. We appreciate your patience and will get back to you as soon as possible.

For faster respond, text or email (909) 366-4712

Email: support@blueoakcounselingservices.com

For more information and online booking, please visit our website below.
www.blueoakcounselingservices.com

Name *

Phone

Online Services

Individual therapy

Couples therapy (private pay only $185/session)

Family therapy

Other:

The reasons for seeking online/video therapy *

Depression

Anxiety

Relationship issues

Trauma/ PTSD

Grief/Loss

Stress management

Coping skills

OCD

ADHD

EMDR

LGBTQ

Postpartum

Other:

Required

Availability for therapy - day/time

Morning 9am-12pm

After 1pm

Evening 5pm -8pm

Other:

How would you like to pay for therapy services?

Self pay / out of pocket

Kaiser Southern CA

Kaiser Northern CA

Cigna

Aetna

Optum or United HealthCare

Anthem

EAP (need authorization)

Blue Shield of CA

Other:

Clear selection

How often would you like to attend therapy?

Weekly

Bi-weekly

Monthly

Other:

Best time to contact you

9am-12pm

1pm-3pm

4pm-5pm

Other:

How did you hear about us?

What else do you want us to know?

Submit

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