Contact Us to Get Started
Name
*
First Name
Last Name
Client's Name (if not yours)
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Therapy Service requested
*
Child 6-10 years old
Child 0-5 years old
Preteen/Tween 11-13 years old
Adolescent 14-17 years old
Young Adult
Adult Therapy
Family therapy
Couples therapy
Preferred Location(s)
*
Mission Valley
El Cajon / Rancho San Diego
Scripps Ranch
Telehealth in California
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Insurance Information
*
Insurance, Plan & Member/Policy ID # | DOD or DBN # | Self Pay | EAP Auth #
Upload your Insurance Card - Front
Upload a File
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Choose a file
Cancel
of
Upload your Insurance Card - Back
Upload a File
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Choose a file
Cancel
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Preferred Day(s) and Time(s)
Brief Reason for Treatment
*
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