Therapy Request Form

Tell us a little about what you need and a team member will contact you.

Therapy Request Form

Please provide the following information to initiate services. If you plan to use insurance, gather your insurance details to speed up the process. A team member will contact you within 5 business days. This form is encrypted for security.

Leave this field empty

Client's first & last name *

Client phone number *

Client's email address *

Physical address with ZIP code (for emergency purposes) *

Client's date of birth *

Age of client *

Contact person (if different than above)

Type of therapy *

Individual Therapy Child or Adolescent Therapy Couples Therapy Psychological Testing Group Therapy

Therapy preference *

Online In-person

If in-person, which office location do you prefer?

La Mesa, CA El Centro, CA Online

Is there a particular therapist you'd like to see? (Write 'None' if not)

Why are you seeking therapy? *

How are you paying for services? *

Self Pay Insurance Victim of Crime (CalVCB)

Your current insurance provider (if using insurance)

Insurance details: name, policy holder, member ID#, and insurer phone (or write N/A if self-paying)

For couple/family therapy, list each person: full name, phone, email, address, gender, DOB (or N/A)

How do you identify? *

Male Female

How did you hear about us?

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