Appointment Request Form
Please submit our pre-intake form. Our staff will reach out very soon to setup your initial appointment! Once confirmed, you will be required to complete our full intake screening. The initial appointment is $40 payable at the time of your appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How do you prefer to be contacted?
*
Please Select
Call
Text
Email
What type of therapy are you seeking?
*
Please Select
Individual
Couples
Child
Family
Conjoint
Group
By clicking below, you confirm that you currently reside in California.
*
Please Select
Yes, I live in California.
By clicking below, you acknowledge that you will be required to complete our full intake screening form before your initial session.
*
Please Select
Got it!
Please choose the date and time of your initial 50 minute intake. The appointment will be held via telehealth. You will receive a confirmation email from the Clinical Director and from the intake counselor prior to your appointment
Submit
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