Appointment Request Form

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Email *

Your name

Your Phone Number

Which service(s) are you seeking? (check all that apply)

Individual therapy for an adult

Individual therapy for a child or teenager

Assessment, testing, or evaluation services

Neurofeedback

Family therapy

Couples or relationship counseling

Parenting support and/or co-parenting support (coaching/consultation)

Single session (one meeting, online)

Groups: social groups, RPG groups, games groups, discussion groups, therapy groups, parent groups, other groups

Consultation on neurodiversity, neuro-differences, autism, ADHD, gifted/2e, academics, education, IEP, homeschooling, management support in the work place

Clinical Supervision

Speaking engagements

Minecraft: I would like to get whitelisted to play on TheraThrive's Minecraft server (TheraThriveMC)

Other:

Age of client(s)

4 years old or younger

5-11 years old

12-17 years old

18 years old or older

If the client is under age 18, do all legal parents/guardians give consent?

Yes

Other:

Clear selection

Please indicate your meeting location preference

Lafayette Office (SF East Bay)

Burbank Office (Toluca Lake/LA Area)

Online (video conference)

Other:

Days you can schedule (days indicated below are in the Pacific Time Zone, please adjust if you are in a different time zone or write in under "other")

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

I'm flexible

Other:

Times you can schedule (times indicated below are Pacific Time, please adjust if you are in a different time zone or write in under "other")

8am-12pm

12pm-4pm

3:30pm and after

I'm flexible!

Other:

Please briefly describe what you are seeking help for, and/or share information that would be helpful for us to know.

Preferred Therapist

For information about our professionals, visit: https://www.therathrive.com/about/professionals

Michael Sacco, LPCC: Licensed Therapist, has current openings, Toluca Lake/Burbank office and online, $229 per 45-50 minute individual therapy session (group fee $57/hr)

Alissa Cohen, LPCC, Credentialed School Psychologist: Licensed Therapist and Licensed Assessor, has current openings for therapy and assessment, Toluca Lake/Burbank office and online, $229 per 45-50 minute per individual therapy session (assessment fees vary; group fee $57/hr)

Arielle Rabby-Chia, LPCC, LMFT: Licensed Therapist and Licensed Assessor, has current openings for therapy and assessment, Toluca Lake/Burbank office and online, $229 per 45-50 minute per individual therapy session (assessment fees vary; group fee $57/hr)

Heather Hanford, AMFT: Senior Associate Therapist, has current openings, Toluca Lake/Burbank office and online, $215 per 45-50 minute individual therapy session (group fee $57/hr)

Luke Tanaka, APCC, AMFT: Associate Therapist, has current openings for therapy and neurofeedback, Lafayette office and online, $195 per 45-50 minute individual therapy session (group fee $57/hr)

Kiara Vuppala, APCC: Associate Therapist, has current openings, Lafayette office and online, $195 per 45-50 minute individual therapy session (group fee $57/hr)

Lydia Wang Koerner, AMFT: Senior Associate Therapist, has limited openings, Lafayette office and online, $215 per 45-50 minute individual therapy session (group fee $57/hr)

Katie Malone, LPCC, LMFT: Clinical Director, current openings for assessments and neurofeedback, limited availability for consultation, therapy caseload is full, Lafayette office and online, $300 per 45-50 minute therapy/consultation session (assessment fees vary)

Grace Malonai, PhD, LPCC: Executive Director, current openings for assessment and neurofeedback, limited availability for consultation, therapy caseload is full, Lafayette office or online, $300 per 45-50 minute therapy/consultation session (assessment fees vary)

First available appointment

Do you reside in the state of California? (for online/telemental health)

Yes

Other:

Clear selection

If not California, which state, province and/or country do you reside in?

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Thank you!

We sincerely appreciate your taking the time to reach out, and look forward to connecting soon.

Please tap the SUBMIT button to send us your request. Thank you!

CONFIDENTIALITY NOTICE:
This form collects information necessary to contact you and help us get started. We are committed to your privacy and will never share your personal information. Please do not include confidential or private information regarding your health condition in this form. By clicking submit, you agree that the email address and phone number you provide may be used to contact you. Consent is not a condition of purchase or services. Check out our privacy policy for the full story on how we protect and manage your submitted data: https://www.therathrive.com/privacy-policy.

A copy of your responses will be emailed to the address you provided.

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