• Pre-Consult Intake Form

    A brief, confidential first step to explore if TODOS Therapy is the right fit for you.

  • Welcome, and thank you for taking this step.

    Before our call, I am asking you to complete this brief intake form. It helps me show up prepared and make the most of our time together — so we can focus on you and what you need, rather than the basics.

    This form takes about 15 to 20 minutes to complete. Your answers help me understand what you are looking for and how I can best support you.


    Your privacy matters.

    Everything you share here is confidential and protected under HIPAA — the federal law that safeguards your health information. Your responses will only be used to prepare for our consultation call and will never be shared without your explicit permission.

    This form is intended only for the person completing it. If you received this link by mistake, please do not fill it out and notify us at help@todostherapy.com so we can correct the error.

    Completing this form does not establish a therapist-client relationship, but it does help me respond to you thoughtfully and with care.

     

  • Note: I am currently licensed to practice in California only.

  • What will happen during the consult call?

  • During this call, we will:

    • Briefly discuss what you’re looking for support with
    • Talk through which service may be a good fit
    • Review my approach and the care available at TODOS Therapy
    • Go over possible next steps
    • Answer any questions about therapy, cost, or scheduling

  • What the Consult Is Not!

  • This consult is not:

    • A therapy session
    • A crisis or emergency service
    • A space for in-depth clinical assessment or diagnosis
    • If you’re experiencing a mental health emergency, please call 988 for direct help and immediate support.

  • Confidentiality & Reassurance

  • Your privacy is important to me. The information you share here is confidential, protected, and complies with HIPAA regulations.

    Submitting this form does not establish a therapist-client relationship, but it helps me respond thoughtfully and respectfully to your request(s).

    It’s okay if you’re not sure what you need yet. Many people come to this consult feeling unsure, overwhelmed, or just wanting to explore options—that’s exactly what this space is for.

  • Accessibility & Cultural Care

  • I strive to offer culturally responsive, affirming care for Latinx, BIPOC, and marginalized communities.

    If there’s anything you want me to know about your needs, access considerations, or concerns, you’ll have space to share that later in this form or email directly: help@todostherapy.com

  • Do you have any accessibility needs for our call?
  • If you checked yes to accessibility needs, what kind?

  • Basic Contact Information

  • Format: (000) 000-0000.

  • Referral Source

  • How did you hear about TODOS Therapy or me?
  • If someone referred you (e.g., medical provider or therapist), may I have their name? (This is optional and will only be used to thank them for the referral.)

  • Story of Referral

  • What kind of support are you looking for? (Check all that apply)

  • Mental Health History

  • Have you ever been in therapy before?
  • Have you ever been diagnosed with a mental health disorder?

  • Risk Assessment

  • Are you currently struggling with suicidal ideation and/or self-harming ideation?

  • Payment Terms & Fee Structure

  • Payment Terms

    • The first payment is due at the time of service. All payments will be submitted at the end of each session.
    • A valid payment method must be kept on file.

    Payment Platform

    • TODOS Therapy uses Ivy Pay, a secure, HIPAA‑compliant payment platform designed specifically for mental health services.
    • Ivy Pay allows for contactless, card‑on‑file payments and automatic receipts.
    • By engaging in services, you agree to the use of Ivy Pay for payment processing.

    Insurance Information

    • TODOS Therapy may be an out‑of‑network provider for many insurance plans.
    • Clients are responsible for understanding their insurance benefits, including out‑of‑network reimbursement, deductibles, and copays.
      TODOS Therapy does not provide superbills.
    • Clients are responsible for understanding their insurance benefits, including out‑of‑network coverage, deductibles, and copays.
    • Insurance reimbursement is not guaranteed, and payment for services remains the client’s responsibility.
  • Who will be responsible for paying for therapy?

  • Below you will see information about my fees for the services I provide.

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  • Would it be helpful to spend some time discussing more in-depth about my sliding scale options during the call?

  • Anti-Oppressive & Anti-Racist Fee Structure

    Brief Overview

  •  TODOS Therapy uses an anti‑racist and equity‑informed fee structure designed to increase access to care while honoring sustainability and fairness. Fees are discussed collaboratively during your consultation or intake session.

    This structure acknowledges the impact of systemic inequities, generational wealth gaps, and barriers to mental health care—particularly for BIPOC and historically marginalized communities.

  • Redistribution (125%)

    This option is for those who have the means to pay more. By choosing this rate, you’re helping to cover the difference for those who cannot afford the full cost. It’s a way to practice wealth redistribution and support a more equitable community.

    Full Cost (100%)

    This is the actual cost of my offering. If you can afford this rate, you’re paying the fair value of the service.

    Sustain (~75%)

    This option is designed for those who need some financial relief but can still contribute to the sustainability of the service.

     Solidarity (~50%)

    This is for those who would benefit from significant financial support to access the services they need.

    Reparations (~35%)

    This price is the lowest amount I can charge. It’s intended for those who have been historically marginalized and face significant financial barriers. This rate is about acknowledging systemic inequities and providing access to those who need it most.

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  • Either way, we will review the payment information and fee structure together and explore which option feels most aligned with, accessible, and sustainable for you during the consultation call.

  • Therapist Preferences

  • You know yourself best. I work with clients navigating ADHD, financial trauma, gender identity, chronic illness, LGBTQ+ experiences, burnout, and more — but I also know that what matters most is not always on a list. Is there anything else I should know about you?
  • Are you currently looking or contacting other therapists?
  • Do you need help looking for other therapists or resources?

  • Disclaimer

  • This consultation call is not a therapy or coaching session. It's a 15–20 minute informal meeting to see if we're a good fit. If you're in crisis or need immediate help, please contact 988 or go to your nearest emergency room.
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