Client Intake Form

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Client Intake Form

Please fill out the following form to help us understand your mental health needs so that we can match you with one of our therapists. We strive to respond to all requests for services within 2 business days.

If you need immediate support, please call 211 for connection to community resources, or 988 if you are experiencing a mental health crisis.

First and Last name (please do enter the name you go by here!) *

Email Address *

Phone Number *

Date of Birth *

YYYY

Are you looking for in-person or telehealth sessions?

In-person

Telehealth

Open to both

Clear selection

Will you be paying for services out of pocket or using insurance?
*

Cash

Partnership Health Plan

Anthem

Medi-cal

Other:

Please share your primary concern(s). Why are you seeking therapy at this time?

Knowing a bit about your identity helps up connect you with a therapist who may be a good fit. Is there anything important about your identity or cultural background we should know?

Please select the therapist you are interested in seeing:

Any/No preference

Dylan

Corina (telehealth only)

Toni

Fia

Frankie

Ryan (telehealth only)

Other:

Do you have a work or school schedule? Please list some days and times you are usually available for regular appointments. Please be aware our office is open Monday-Friday 9am-6pm.

How do you prefer we contact you to schedule an intake appointment?

Text Message

Voice Call

Clear selection

Submit

Clear form

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