Abundance Therapy Center- Therapy Appointment Request

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Therapy Request Form By signing this form, I agree to give Abundance Therapy Center permission to call, text or leave me voicemails.
Client's Legal Name
Phone #
Email Address
Client's Birthdate
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How did you hear about us?
Search Engine (Google, Yahoo, etc.)
Insurance Referral/Directory
Primary Care Physician
Recommended by friend/family/colleague
Care Solace
Social Media
UCLA Health (PCP Referral)
UCLA Student Health Center
USC Student Health Center
Other School Referral
Newspaper Ad (Larchmont Chronicle, etc)
Referred by another agency
Other:
If you selected other, please explain:
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Are you a California Resident?* This field is required.
YESNO
4
Would you like to schedule for telehealth sessions or in-person sessions?* This field is required.
Virtual/Telehealth Sessions
In-Person Sessions
Either one works
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Are you using insurance to pay for sessions?* This field is required.
Use my insuranceSelf-Pay
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Select your insurance provider.* This field is required.Please select your PRIMARY insurance. If you have two insurances, you must verify which one is PRIMARY and select the PRIMARY to ensure sessions are covered. If your insurance is not listed, we are not in-network with your insurance. Please select Out of Network Benefits or return to the previous screen and select "Self-Pay".
Aetna
Aetna USC Student
Anthem Blue Cross HMO/PPO
Anthem Medi-Cal
Blue Shield PPO
Blue Shield Medi-Cal (Blue Shield Promise Health Plan)
Blue Shield Medicare
Cigna
Cigna EAP
Kaiser Permanente
LA Care Medi-Cal
Optum
Oscar
Evernorth
HealthNet/ MHN Commercial HMO/PPO
HealthNet/ MHN Medi-Cal
UC SHIP for Students
United
Magellan
Molina Medi-Cal
My insurance is not listed but I have a PPO plan and want to use Out of Network Benefits.
Other
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What type of appointment would you like to schedule?* This field is required.
Individual Sessions (1 on 1)
Individual Sessions for Minor Aged 0-12 (Child)
Individual Sessions for Minor Aged 13-17 (Teen)
Couples Sessions
Family Sessions
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Has your partner ever physically hurt you?* This field is required.(and vice versa)
YESNO
9
Do you feel safe in your home?* This field is required.
Yes
No
Sometimes
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Are you under a conservatorship?* This field is required.
YESNO
11
Is the client 18 years or older?* This field is required.
YESNO
12
Parent or Legal Guardian's nameIf client is a minor.
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Have you (or your child/partner) been hospitalized in the past 6 months due to psychiatric reasons?* This field is required.
YESNO
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What was the reason and duration of hospitalization? When you were discharged, did you receive any treatment prior to today? Were you prescribed medications, and are you still taking them?
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Ok
Ok
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Have you (or your child/partner) had thoughts of hurting yourself or others in the past 2 weeks?* This field is required.
YESNO
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Were these thoughts about hurting yourself or someone else? Did you or do you intend to act on these thoughts?
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Large
Normal
Small
Ok
Ok
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In the last 2 weeks, have you (or your child/partner) heard or seen things that were not really there?* This field is required.
YESNO
18
Can you explain what you heard or saw?
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Large
Normal
Small
Ok
Ok
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Are you (or your child/partner) currently dealing with any substance abuse, including alcohol?* This field is required.
YESNO
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What substance was it? When was the last time you used it? How often do you use it? Are you currently in treatment or have you been in treatment?
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Large
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Small
Ok
Ok
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Are you currently seeing another therapist?* This field is required.
YESNO
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What's bringing you to therapy?* This field is required.Select all that may apply.
Abuse
ADHD
Academic Stress
Anger Management
Anxiety
Autism Spectrum Disorder
Bipolar Disorder
Career/ Work Stress
Court Ordered Therapy
Chronic Illness/Pain
Cultural Issues
Depression
Eating Disorder
Grief/ Loss
Learning Disability
LGBTQIA+ Issues
Men's Issues
Mood Disorder
Non-Substance Addiction
Relationship Issues
Self-Esteem
Self Harm
Substance Abuse
Suicidal Ideation
Trauma/PTSD
Women's Issues
Other
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Is there anything else you would like us to know to help us match you with a best-fit therapist?Let us know if you are looking for specific modalities (DBT, EMDR, etc.), languages, have a particular therapist in mind, or have any other information that you want to note here.
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Couples Therapy Disclaimer & Notice of Fees* This field is required.We cannot usually accept insurance for couples therapy, because insurance companies usually only cover treatments that are seen as medically necessary. Our fees for couples therapy are $145-$190 per session, depending on the therapist you and your partner work with.
I have read the information presented above. By filling out the next form, I understand and acknowledge that I will not be able to use insurance for my couples therapy. Payment shall be made using a credit, debit or HSA card.
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At this time Abundance Therapy Center's clinical staff are licensed to provide services only to California residents. Please visit https://www.psychologytoday.com/us to find a licensed therapist in your state.
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We understand how difficult it can be to find a therapist when you need one most. Unfortunately, due the overwhelming demand for mental health services caused by COVID-19 all available times with therapists who accept your insurance type are currently booked up! We do recommend reaching out if you want another practice recommendation or have any other questions about what we offer here at Abundance Therapy Center. Our team truly regrets any inconvenience this may cause.* This field is required.If you would like a list of referrals please enter your name and email address. One of our care coordinators will email you with referral options.
Name
Email Address
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