Appointment Request/Solicitud de Cita
Legal Name/Nombre Legal
First Name/Primer Nombre
Last Name/Apellido
Preferred name/Nombre preferido
First Name/Primer Nombre
Last Name/Apellido
Phone Number/Numero de Telefono
Please enter a valid phone number./Por favor entre un numero valido
Email/Correo electronico
example@example.com
Do you have insurance?/Tiene aseguranza
Yes/Si
No
Who is your insurance provider?/Quien es su proveedor de aseguranza?
*
Please Select
Aetna
Aetna EAP
Carelon EAP
La Care
La Care Covered CA
Cigna
Cigna EAP
Lyra EAP
Mines and Associates EAP
Kaiser Permanente
Optum
Optum EAP
Spring Health
Are you a new patient?/Es un paciente nuevo
Yes/Si
No
Preferred method of delivery/Manera preferida
In Person/En Persona
Telehealth/Video
Both in person and telehealth/Los dos
Flexible
Type of appointment
Please Select
Child/adolescent therapy / terapia para ninos
Adult individual therapy / terapia individual adulto
Couples therapy /terapia de parajas
Family therapy/terapia familiar
How did you hear about us?/ Cómo se enteró de nosotros?
Please Select
Online/ En Linea
Friend / Family/ Amigo(a) / Familiar
Insurance/ Seguro médico
Other/ Otro
Any comments, concerns?/comentarios
Submit
Should be Empty: