• For all Inpatient services, please contact Herrick Hospital directly at 510-204-4040.

  • For all Day Treatment services (PHP & IOP), please contact Herrick Hospital directly at 510-204-4040.

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  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
  • Are you fluent in English?
  • Primary languages spoken fluently

  • If your primary residence is out of the state of California, we are unable to see you because our physicians are licensed in the state of California

  • Are you a referring provider?*
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  • If you are a Kaiser member, you will need to obtain an authorization referral for medical psychiatry services before you can be scheduled.

  • Insurance Subscriber Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
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  • Do you have Secondary Insurance?*
  • What diagnoses have you received from a medical or mental health provider in the past?*
  • What diagnoses have you received from a medical or mental health provider in the past, for which you are now in remission?
  • What diagnoses have you received from a medical or mental health provider in the past, but aren't a problem right now?
  • What symptoms are you currently experiencing that led you to seek care?*

  • Unfortunately, we do not currently treat patients solely for Addiction/Substance Abuse.

  • Our Outpatient department is not an urgent care clinic, and we do not accept drop-ins. We recommend that you go to your nearest emergency room if you are in need of urgent/emergency services.

  • Unfortunately, we do not currently treat patients solely for Eating Disorders.

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  • History of Suicide Attempts?*
  • Are you currently taking psychiatric medications?*
  • Have you ever been hospitalized for a psychiatric condition?*
  • Are you currently in therapy?*

  • Our primary Outpatient services involve medication management and we are unfortunately not accepting psychotherapy/therapy-only patients at this time.

  • Are you open to medications as part of your treatment?*
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