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 3 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 Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

YYYY

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

Please select the therapist you are interested in seeing:

Any/No preference

Dylan

Max

Corina

Toni

Are you looking for in-person or telehealth sessions?

In-person

Telehealth

Open to both

Clear selection

What is your work/school schedule? Please list some days and times you are usually available for regular appointments. Please be aware our evening availability is extremely limited. We are not currently offering weekend appointments.

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

Cash

Partnership Health Plan

Anthem

Medi-cal

Other:

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 we should know? (cultural identity, queer/trans, race/ethnicity, religious beliefs?)

Submit

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