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Blue Oak Online Intake Form
Please fill out the form below, and we will contact you in one to two business days.
If you are currently experiencing a mental health crisis or emergency, please call 1-800-273-8255 or 911 for crisis support or go to your nearest emergency room.
*Our low-fee therapy slots are currently full. Please check back later. We apologize for the impact this may have.
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Email
*
Your email
Full Name
*
Your answer
Age
*
Your answer
Pronouns
*
Select all that apply
they/them
she/her
he/him
Other:
Required
What is your gender?
*
Example: Two-Spirit, Transgender, Genderqueer, Non-binary, Gender non-conforming, Male, Female, Prefer not to say
Your answer
What is your sexual identity/sexual orientation?
*
Example: asexual, bisexual, lesbian, gay, queer, pansexual, aromantic, questioning or unsure, Prefer not to say
Your answer
Which category best describes you?
*
select all that apply
African
African-American/Black
Asian-American
East Asian (including Chinese, Japanese, Korean, Mongolian, Tibetan, and Taiwanese)
Hispanic
Latinx
Indigenous American/First Nations (including Native American/American Indian, Alaskan Native, Pacific Islander, and Native Hawaiian)
Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc.
South Asian (including Bangladeshi, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan)
Southeast Asian (including Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese)
White
Prefer not to say
Other:
Required
Phone Number
*
Your answer
Email address
*
Your answer
What is the best way to reach you?
*
select all that apply
Phone
Email
Text message
Required
If by phone, what are the best times to contact you?
*
Please specify time and day of the week (Example: Mon 5-6pm, Wed 2-4pm, Sat 9am-12pm). If not applicable please write NA
Your answer
When we contact you, can we use our agency name in the message?
*
Yes
No
Are you currently a resident of California?
*
Yes
No
What type of therapy are you looking for?
*
Individual
Couple
Family
Child/teen
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