New Patients | Berkeley Therapy Ins

New Psychotherapy Patient Inquiry

Thank you for your interest in our psychotherapy services*. Please provide the following information so we may quickly respond to your request:

Name

Phone Number

Email

Referred by

Gender

Sexual Orientation

*PLEASE NOTE: Contact by email does not constitute a working therapeutic relationship or doctor-patient relationship.This form is to be completed only by the person seeking services or by a parent for a minor child.

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