Appointment Request Form

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Language Preference?
EnglishEspañol, Mandarin (普通话), or Tagalog
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Español: En este momento, Framework no cuenta con un terapeuta que hable español. Le recomendamos que visite el siguiente enlace para localizar referencias:

https://www.psychologytoday.com/us/therapists/91602?category=spanish

Mandarin: 池医生目前正在休产假。预计她将于2024年底返回。届时请联系我们接受治疗。如果您需要提前预约，请致电“Counseling West”：(818) 990-9898

Tagalog: Mangyaring ipadala ang iyong impormasyon sa "Hello@FrameworkPsych.com":

pangalan

numero ng telepono

araw ng kapanganakan

larawan ng iyong insurance card
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Are you 18 or older?If completing this form for another person, will the client be 18 or older? Framework only provides psychological services to adults.
YESNO
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Unfortunately, Framework does not work with children or adolescents. For minors, we recommend the following clinics:

California: Dr. Albert Knapp & Associates

https://dralbertknapp.com

Illinois: Atlas Behavioral Health

https://www.atlasbehavioral.com/
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Where do you live?* This field is required.
California
Illinois
Another state
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Availability for Illinois Residents* This field is required.Our current availability for your selection is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Male Therapists: Weekdays, Mid-Day 11am - 3pm CST / ONLINE THERAPY
Male Therapists: Weekdays, Evening 3pm - 7pm CST / ONLINE THERAPY
Female Therapists: Weekdays, Mid-Day 11am - 3pm CST / ONLINE THERAPY
Female Therapists: Weekdays, Evening 3pm - 7pm CST / ONLINE THERAPY
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Therapy Request Form - Illinois* This field is required.Thank for you your answers! Please provide your information below so that we can research your insurance benefits, provide you a quote, and help you schedule. (This form is secure and HIPAA-compliant.)
Full Legal Name? (First and Last)
Phone Number?
Email Address?
Date of Birth?
Please Select
Please Select
Pay by credit card
Aetna
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield Out of State (not IL)
Insurance Provider?
Insurance Member ID#? ("NA" if paying by credit card)
Please Select
Please Select
Individual Therapy
Couples Therapy
Service Requested
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Framework's therapists are licensed to provide services to residents of California or Illinois. We are unable to provide services to those who live outside of these two states. We recommend visiting the link below to find a therapist who is licensed in your home state:

https://www.psychologytoday.com/us
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Which service are you interested in?* This field is required.
Individual Therapy (1 on 1)
Group Therapy (Support Group)
Couples Therapy (Relationship)
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Do you prefer to use your health insurance?* This field is required.
Use my insurancePay by credit card.
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Please select your insurance provider.* This field is required.If an insurance is not listed below, we are unable to accept the insurance for payment. Please return to the previous screen to select "pay by credit card."
Aetna
Anthem Blue Cross
Beacon
Blue Cross Blue Shield Out of State (not CA)
Blue Shield of California
Carelon
Cigna
Evernorth
First Health
L.A. Care
Lucet
Magellan
Medicare
Meritain
Optum
Oscar
Tricare / TriWest
U.C. SHIP for Students
United Healthcare
UMR
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Group Therapy Request Form* This field is required.Thank for you your answers! Please provide your information below so that we can research your insurance benefits, provide you a quote, and help you schedule. (This form is secure and HIPAA-compliant.)
Legal Name?
Email Address?
Phone Number?
Date of Birth?
Please Select
Please Select
Pay by credit card.
Aetna
Anthem Blue Cross
Blue Cross Blue Shield out of state (not CA)
Beacon
Cigna/Evernorth
L.A. Care
Medicare
Optum
Oscar
Tricare
U.C. SHIP for Students
United Healthcare
Payment Preference?
Insurance Member ID#? (N/A if paying by credit card)
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Couples Therapy* This field is required.Thank for you your answers! Please provide your information below so that we can research your insurance benefits, provide you a quote, and help you schedule. (This form is secure and HIPAA-compliant.)
Required: Partner #1 Legal Name?
Required: Partner #1 Email Address?
Required: Partner #1 Phone Number?
Required: Partner #2 Legal Name?
Required: Partner #2 Email Address?
Required: Partner #2 Phone Number?
Please Select
Please Select
Weekdays 8am-12pm
Weekdays 12pm-4pm
What is your availability for couples therapy? (We do not have evening or weekend availability at the moment.)
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Couples Therapy Payment Preference* This field is required.Thank for you your answers! Please provide your information below so that we can research your insurance benefits, provide you a quote, and help you schedule. (This form is secure and HIPAA-compliant.)
Please Select
Please Select
Pay by credit card
Aetna
Anthem Blue Cross
Blue Cross Blue Shield Out of State (not CA)
Beacon
Carelon
Cigna
L.A. Care
Medicare
Optum
Oscar
Tricare
U.C. SHIP for Students
United Healthcare
Required: Payment Method
Required: Insurance Member ID# ("N/A" if paying by credit card)
Required: Name of Policy Holder ("N/A" if paying by credit card)
Required: Date of Birth of Policy Holder ("N/A" if paying by credit card)
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Aetna / First Health / Lucet / Meritain - Availability:* This field is required.Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays 8am-3pm / Online by Videochat / Female Therapists
Tuesdays 8am-2pm / In-Person in North Hollywood / Female Therapists
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Anthem Blue Cross / U.C. SHIP / Out-of-State BCBS - Availability:* This field is required.Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays 8am-4pm / Online by Videochat / Female Therapists
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Beacon / Carelon / L.A. Care - Availability:* This field is required.Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays 9am-5pm / Online
Thursdays 9am-5pm / North Hollywood
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Cigna / Evernorth - Availability:* This field is required.Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays 8am-4pm / Online by Videochat / Female Therapists
Tuesdays 8am-2pm / In-Person in North Hollywood / Female Therapists
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Medicare/ Tricare / TriWest - Availability:* This field is required.Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays Mid-Morning / Online Videochat / Female Therapists
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Optum / Oscar / United / UMR - Availability:Our current availability for your selections is listed below. We're unable to offer you additional availability other than what is listed below. We ask that you only select a time and appointment location that will work for you. Thank you.
Weekdays 9am-12pm / Online by Videochat / Female Therapists
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Unfortunately, due to the extremely high demand for mental health services, all Framework therapists who accept your specific insurance are fully booked at this time.

We are actively working to identify additional availability and hope to accept new clients with your insurance type soon.

We have alternatives we hope you'll consider:

Individual Therapy Outside of Insurance: We may have therapists available outside of your insurance network. If you prefer individual therapy and are open to seeing a therapist who does not accept your insurance, please refresh your page and next time select "Pay By Credit Card" when prompted for your payment preference.

Group Therapy: If you need treatment for ADHD, we encourage you to consider our group therapy program, Re-Focus. If you would like to participate in group therapy, please refresh your page and next time select "Group Therapy" when prompted.

Receive Referrals: If you prefer individual therapy with a therapist who accepts your insurance, and need treatment in a timely manner, please click this link to view a list of other mental health clinics who accept insurance.

Thank you for understanding as we work to serve our community.
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Please take a moment to examine the front of your insurance card.

In California, Blue Cross Blue Shield is two separate insurers.

In Network: If you have Anthem Blue Cross of California, or a Blue Cross Blue Shield Plan from another state other than California, then we can bill your insurance for services. Please refresh your page and select "Anthem Blue Cross" when prompted for your insurer.

Out of Network: If you have Blue Shield of California then unfortuantely we cannot bill your insurance for services. If you still wish to proceed with Framework, please refresh your page and select "Pay by Credit Card" when prompted for your payment preference. Our rates for paying via credit card are linked here. If you need to use your insurance to cover services, we recommend inquiring with PCPASF.com.

Thank you
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Individual Therapy Request Form - California* This field is required.Thank for you your answers! Please provide your information below so that we can research your insurance benefits, provide you a quote, and help you schedule. (This form is secure and HIPAA-compliant.)
Required: Full Legal Name? (First and Last)
Required: Email Address?
Required: Phone Number?
Required: Date of Birth?
Please Select
Please Select
Pay by credit card
Aetna
Anthem Blue Cross
Blue Cross Blue Shield Out of State (not CA)
Beacon
Carelon
Cigna
L.A. Care
Medicare
Optum
Oscar
Tricare
U.C. SHIP for Students
United Healthcare
Required: Payment Method (Please Scroll Down)
Required: Insurance Member ID#? ("NA" if paying by credit card)
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OPTIONAL (Feel free to skip)Would you like to upload a photo of your insurance card? This can help expedite the preparation of your quote.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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OPTIONAL (Last question, we promise! But feel free to skip & submit..)Are there any special requests you'd like us to consider when matching you with a therapist? Your match is based upon several variables including the scheduling preferences indicated on your appointment request and your insurance coverage. We'll make every attempt to match you to a therapist you prefer to see. However, we consistently have very high demand for our services which means we may match you with another talented therapist on our staff based on scheduling availability. We encourage you to have a session with the recommended therapist in order to determine if it is a mutual fit. If it is not a good match, please let us know so that we can offer you referral options.
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