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  • Intake Form

    Kindred Heart Therapy Group

  • Welcome to Kindred Heart Therapy Group's intake form.  Please fill out all sections of this form & submit it back to our team.  After we receive your form our team will review it and a clinician will reach out to schedule. 

     

    Thank you, Kindred Heart Therapy Group, A Non-Profit Corporation!

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  • You will receive a confirmation email once your online intake form has been successfully submitted.

  • If you are seeking additional services from our office please use this link.  A new tab will open with the form you need to complete to request those services.

  • If the client/child is under the age of 12 years old please answer the following:

  • Kindred Heart Therapy Group has multiple clinicians that offer a variety of service types.  The following questions are regarding client insurance information or payment preferences.

     

    Kindred Heart Therapy Group accepts the following insurances: Anthem Medi-Cal, Anthem Commercial, HealthNet Medi-Cal, HealthNet Commercial, Adventist Health, Partnership Health Plan, Carelon Commercial, Magellan Behavioral Health, Aetna & several other insurances. 

     

    We also offer sliding scale options, such as:

    • $0 - $100+ per session for Trainees: clinicians finishing graduate school with 0 - 700 supervised clinical hours.

    • $100 - $125+ per session for Freshman Associates: post-master's clinicians accruing approximately 500-1,000 supervised clinical hours toward licensure.

    • $125 - $200+ per session for Sophomore Associates: post-master's clinicians with roughly 1,000-2,000 supervised clinical hours.

    • $135 - $225+ per session for Senior Associates: post-master's clinicians having about 2,000-3,000 supervised clinical hours.

    • $145 - $300+ per session for Licensed Clinician who have accrued their 3,000 supervised clinical hours and passed their Law and Ethics and Clinical exams

  • Failure to provide accurate insurance information will void your intake form.  Please provide the name of all your insurance providers and your member ID #.

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  • Failure to provide your available times for your intake session will void or delay your intake process.

  • Intake Form

    Kindred Heart Therapy Group
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  • Cancellation Policy:

    1. Regular attendance in weekly therapy is essential for treatment. Kindred Heart Therapy Group requires a 24-hour notice if a client needs to cancel a session. *
    2. After one no-show or late cancellation, there is a warning given by your therapist. *
    3. After the second no-show or late cancellation, clients are placed on their therapist's waiting list, where they can be offered sessions during their therapist's weekly openings      *   


    By electronically signing this document, I agree that the information I have provided in this form is true to the best of my ability.

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