Appointment Request Form

Email *

Your name

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

Assessment, testing, or evaluation services

Family therapy

Couples or relationship counseling

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

Group therapy, games groups, or discussion groups

Consultation on gifted matters, high sensitivity, or high functioning Autism

Clinical Supervision

Minecraft server

Other:

Age of client(s)

4 years old or younger

5-8 years old

9-12 years old

13-18 years old

19 years old or older

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

Yes

Other:

Clear selection

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

Rhani Rabago, AMFT: Associate Therapist, accepting new clients, $150 per 45-50 minute individual therapy session (group fee is much lower)

Wendy Rolon, AMFT: Associate Therapist, accepting new clients, $150 per 45-50 minute individual session (group fee is much lower)

Sean M Peterson, AMFT: Senior Associate Therapist, accepting new clients, $150 per 45-50 minute individual therapy session (group fee is much lower)

David Millen, AMFT: Senior Associate Therapist, limited availability to new clients, $175 per 45-50 minute individual therapy session (group fee is much lower)

Deb Simon, PhD, LEP: Licensed Clinical Psychologist, Credentialed School Psychologist, accepting new clients for assessment services, $300 per assessment hour (total assessment cost depends upon type of assessment)

Doug Ronning, LMFT, RDT/BCT: Licensed Therapist, accepting new clients for all groups; individual therapy caseload is full to new clients, $185 per 45-50 minute individual therapy session (group fee is much lower)

Katie Malone, LPCC, LMFT: Lead Therapist, caseload is full to new clients

Grace Malonai, PhD, LPCC, BC-TMH: Director, limited availability, $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?

Thank you!

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

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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.

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