Restore Counseling Center- Therapy Appointment Request

1
Are you a California Resident?* This field is required.
YESNO
2
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
3
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
4
Is the client 18 years or older?* This field is required.
YESNO
5
Parent or Legal Guardian's nameIf client is a minor.
6
Have you (or your child/partner) been hospitalized in the past 6 months due to psychiatric reasons?* This field is required.
YESNO
7
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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8
Have you (or your child/partner) had thoughts of hurting yourself or others in the past 2 weeks?* This field is required.
YESNO
9
Were these thoughts about hurting yourself or someone else? Did you or do you intend to act on these thoughts?
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Ok
10
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
11
Can you explain what you heard or saw?
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Ok
12
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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14
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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Therapy Request FormWe need your information so that we can find the best possible therapist for you and get an estimate of your co-pay & benefits. If you are self-paying instead of using insurance, please enter "N/A" in the Insurance Member ID field. This form is secure and HIPAA-compliant. Please note that if you are using insurance, we require your member ID to verify eligibility and benefits. If you have two insurances, you must verify which one is your PRIMARY INSURANCE and provide us with your PRIMARY INSURANCE to ensure sessions are covered. 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
Please Select
Please Select
Self-Pay/Out of Pocket
Aetna
Aetna USC Student
Anthem Blue Cross HMO/PPO
Anthem Medi-Cal
Cigna/Evernorth
Healthnet/MHN Commercial HMO/PPO
Healthnet/MHN Medi-Cal
Oscar/Optum/United
UC SHIP for Students
Insurance Provider
Insurance Member ID
Client's Birthdate
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:
How did you hear about us?
If you selected other, please explain:
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Couples Therapy Disclaimer & Notice of Fees* This field is required.
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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Couples Therapy Request Form* This field is required.Please enter both partners' contact information and availability. This form is secure and HIPAA-compliant. By signing this form, i agree to give Abundance Therapy Center permission to call, text, or leave me voicemails.
Partner #1, Legal Name
Partner #2 Legal Name
Partner #1, Phone Number
Partner #2, Phone Number
Partner # 1, Email
Partner # 2, Email
What time of the week are you both typically free ? (ex. weekday mornings, afternoons")
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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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