Thank you for your interest in our professional psychotherapy services. To being, please provide the following information:

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Email to Person

Full Name *

First

Last

Will you be the patient? *

• Yes
• No

This form is to be completed by the person seeking services or a legal guardian of a minor.

Date of Birth *

Phone *

Email *

Payment *Select onePrivate Pay/Out-of-PocketAetnaAnthem / Anthem Blue CrossBlue CrossBlue Cross/Blue Shield FEPBlue Shield of CABlue Shield with MagellanCignaHealthNetKaiserMagellanManaged Health NetworkMeritainUC SHIP

If your insurance is not listed we do not accept it at this time. Contact us with any questions.

Gender

Patient PronounsSelect oneShe / HerHe / HimThey / ThemOther

Prefer Therapy In Person or Virtual/Telehealth *Select oneIn Person OnlyTelehealth OnlyBoth are okay

Therapist Gender Preference *Select oneFemaleMaleNon-BinaryAny, no preference

Sexual Orientation

Referred by

Any recent psychiatric hospitalizations

• Yes
• No

Any history of harm to self or others?

• Yes
• No

Any history of substance abuse?

• Yes
• No

What's the best method to contact you? *

• Email*
• Phone – okay to leave message
• Both Email* and Phone/Voicemail

*Contact by email does not constitute a working therapeutic relationship or doctor-patient relationship.

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