Inquiry for services

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Thank you for your interest in receiving therapy services through Open Paths Counseling Center.

Para español: https://docs.google.com/forms/d/e/1FAIpQLSeL9HViuNo5-MrixxgZ4fei8VDbqkALihceDLIYxV3YKyP8cA/viewform?usp=sf_link

If you have any questions or difficulty completing the form, please contact us at (310) 258-9677.

**Disclaimer: Completing this inquiry form does not establish you as a new patient of Open Paths Counseling Center. Our intake coordinator will contact you upon receipt of the completed form. If you have any urgent/emergent or safety concerns, like suicidal thoughts, please call 988 or go to the nearest ER.

Email *

Name (and phonetic spelling) of person completing this form *

Phone number of person completing this form *

Voicemail consent *

If we are unable to reach you, do you consent for us to leave a voicemail message indicating we are calling from "Open Paths"?

Yes

Preferred language for communication *

English

Spanish

Other:

Are you seeking services for yourself? *

If seeking services for another person, please indicate their name(s) in the "Other" space

Yes

Other:

If completing this form on behalf of someone else, please indicate your relationship to the person to receive services.

Parent

Legal Guardian

Partner (for couples therapy)

Other family member (for family therapy)

Other:

Age(s) of person to receive services *

For Individual or Group therapy services: If the person to receive services is over the age of 18 years old and is not a legally dependent adult, please have them complete this form.

What type of therapy services are you interested in? *

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

EMDR Therapy

Required

If interested in our Group Therapy options, which group(s) are you interested in?

Anger Management

Social Anxiety Group

Grief/Bereavement

Positive Parenting

Women's Empowerment (female-identified persons only)

Existence is Resistance: A Trans*/Non-Binary Therapy Support Group

Other:

What is your city of residence? *

We currently are only able to provide services to residents of Los Angeles County.

What is your zip code of residence? *

We currently are only able to provide services to residents of Los Angeles County.

Our office is located in Inglewood, CA (90301). Are you wanting in-person or telehealth services? *

In order to receive telehealth services, you will be assessed for appropriateness to receive telehealth services which includes but is not limited to: access to audio AND video for Zoom sessions, quality internet connection, privacy of space in which you are connecting. You must also be in the state of California at the time of your telehealth sessions.

In-person

Telehealth

Required

How did you find out about our services?

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