Appointment Request Form
Your Phone Number
Which service(s) are you seeking? (check all that apply)
Online counseling or consultation (telemental health)
Single session (one meeting, online)
Individual therapy for an adult
Individual therapy for a child or teenager
Couples or relationship counseling
Group therapy, group games, or group discussions
Age of client(s)
3 years old or younger
4-7 years old
8-12 years old
13-18 years old
19-30 years old
31-59 years old
60-79 years old
80 years old or older
Days you can schedule
Times you can schedule (times indicated below are Pacific Time, please adjust if you are in a different time zone)
3:30pm and after
Do you reside in the state of California? (for telemental health)
For information about our professionals, visit:
Katie Malone, LPCC, LMFT
Bri Tarpey, LMFT, PPS, APCC
Arwin Cotas-Girard, Psy.D.
Doug Ronning, LMFT, RDT/BCT
Grace Malonai, PhD, LPCC, BC-TMH (limited availability)
Please briefly describe what you are seeking help for, and/or share information that would be helpful for us to know.
We sincerely appreciate your taking the time to reach out, and look forward to connecting soon.
Never submit passwords through Google Forms.
This form was created inside of TheraThrive.
Terms of Service