Appointment Request Form

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Please send us a message by using the form and we will place you on our waiting list in the order we receive your request.

Email *

My Name *

Phone *

Email Address *

May We Leave a Message?

Primary Client Name *

Primary Client Age *

Your Relationship to Primary Client *

Myself

Partner/Spouse

Parent

Other:

Required

I'm looking for these services * *

Individual Therapy

Family Therapy

Couples Therapy

Group Therapy

Parent Coaching

Counseling for the Gifted

Required

How did you hear about us?

I'm Looking for Help Related To *

Anxiety & Stress

Depression

Relationship Support

Self-compassion & Self-worth

Family Relationships

Personal Growth

Life Transitions

Grief & Loss

Sexuality

Gender Identity & Expression

Parenting

Fertility/Pregnancy Loss/Pregnancy/Postpartum

Divorce, Separation or Remarriage

ADD/ADHD

Problems at School or Work

Social & Emotional Development

Trauma

The Gifted Population

Other:

Required

Our schedule for Anthem BlueCross and United HealthCare insurance clients are fully booked at this time, would you mind to be added on the waitlist?(Please note that we cannot predict our availability timeline, however, we will contact you based on first-come-first-serve from this waiting list.) *

Yes, please add me to the waitlist. I would like to use my insurance benefit only.

No, I cannot wait and I don’t want to use my health insurance for privacy reason. Please arrange therapy sessions for me. I’m willing to pay out-of-pocket myself.

I have PPO policy with other insurance. I’m paying out of my pocket first but I’ll need a superbill from you to get reimbursement from my insurance company.

My preference for therapist is: *

Wendy Lang (Only provide evaluation and consultation for $300 per 60-minute session)

Michael Britton ($200 for initial evaluation & $160 for 45-minute session)

Leslie Margolis ($240 for initial evaluation & $200 for 45-minute session)

Carolyn Tsou ($240 for initial evaluation & $200 for 45-minute session)

Ariel Yeh ($180 for initial evaluation & $150 for 45-minute session)

Connect me with the best fit

My preference for appointment times are: *

Weekday mornings

Weekday lunches

Weekday afternoons

Weekday evenings

Other:

We understand the hourly rate for private individual therapy is quite high, therefore, we offer group therapy sessions which are quite effective and cost friendly. All our therapists have years of experience in running various group sessions. Would you be interested in participating in the group sessions with us?

Adult Coping with Anxiety Group

Adult Quarter-Life Crisis Group

Postpartum Support Group

Parenting Support Group

Support the Emotional Needs of Gifted (SENG) Model Parent Group

Children Growth Mindset Group

Children’s Anxiety Group

Middle School GirlTalk Group

High School GirlTalk Group

Children/Teens Interactive Social/Emotional Learning Group with Wendy

No, I’d like to keep it individual.

Is there anything else that you would like us to know?

A copy of your responses will be emailed to the address you provided.

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