Appointment Request Form

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Email *

Your name

Your Phone Number

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

Online counseling or consultation only (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 neuro-differences, such as gifted matters, Autism, and/or high sensitivity

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

Please indicate your meeting location preference

In-office (proof of Covid vaccination is required for in-office)

Online (video conference)

Outdoors (walk-and-talk or office outside patio room)

Combination: sometimes online, sometimes in-office, and/or sometimes walk-and-talk or outside patio room

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

Chelsie Crilly, AMFT: Associate Therapist, accepting new clients, $178 per 45-50 minute individual therapy session (group fee is much lower)

Fritz Bixler, APCC, AMFT: Associate Therapist, accepting new clients, $178 per 45-50 minute individual therapy session (group fee is much lower)

Wiley Rogers, AMFT: Associate Therapist, accepting new clients, $178 per 45-50 minute individual therapy session (group fee is much lower)

Wendy Rolon, APCC, AMFT: Senior Associate Therapist, limited availability for new clients, $195 per 45-50 minute individual session (group fee is much lower)

David Millen, LMFT: Licensed Therapist, limited availability for new clients, $249 per 45-50 minute individual therapy session

Katie Malone, LPCC, LMFT: Lead Therapist and Clinical Supervisor, limited openings for new therapy and assessment clients, $300 per 45-50 minute therapy/consultation session

Grace Malonai, PhD, LPCC, BC-TMH: Director, limited openings for assessment and short-term consultation, caseload is full to new therapy clients, $300 per 50 minute therapy/consultation session

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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