New Patient Update List Form

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Welcome. I understand how important and personal the journey towards mental wellness can be. This form is for those who would like to be alerted when I have availability to take on new patients.

Please keep in mind that while I am committed to serving new patients as my schedule allows, the need for immediate mental health assistance should not be delayed. Please reach out to other qualified providers as soon as possible to ensure timely support.

Your Privacy and Security: Your privacy is of utmost importance to us. This form is HIPAA compliant, ensuring the highest standards of data privacy and security for your personal health information. However, as with any online transmission, please be cautious of the information you choose to share via this form.

What services are you seeking?

Individual Psychotherapy

Dating/Relationship Coaching

Psychological Assessment/Diagnostic Evaluation

Case Consultation (for other behavioral health care providers ONLY)

Other:

Full Name:

Email Address: (Enter your preferred email address. This is where we will send notifications about availability.)

Contact Number: (If you prefer, provide a phone number where we can contact you about availability updates.)

Preferred Communication Method: (Please select between Email, Phone, or Text.)

Phone

Text

Clear selection

Optional: How did you hear about Dr. Llerena?

Personal referral (friend, family, etc.)

Health professional referral (doctor, psychiatrist, therapist, etc.)

I am a former client/patient

Online search

Social Media (Facebook, Instagram, etc.)

Psychology Today

Other psychotherapy directories (APA, Good Therapy, ABCT, Div 12, etc.)

Other

Clear selection

Clear form

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