Request an Appointment

Request an Appointment

We're honored you're considering therapy with Full Vida Therapy.
This secure form is used to request a free 10-15 minute consultation and to help determine clinical and logistical fit.

Please answer questions as accurately as possible. You are not required to share details you are uncomfortable providing at this stage.

This does not start therapy and does not establish a treatment relationship.

If we determine fit, you will receive a secure intake packet with additional questions before scheduling.

If you are in crisis or dangerous situations, call 911 or go to the nearest emergency room.
Full Legal Name*

First NameLast Name
Preferred Name (if different)
Date of Birth*

DayMonthYear
Email*

Confirmation Emailexample@example.com
Phone Number*
Preferred Contact Method*
State of Residence*
Who is seeking therapy?*
Age of person requesting therapy*
What is bringing you to therapy at this time? *
(Please provide a brief summary in 2-4 sentences.)
Are you currently experiencing thoughts of harming yourself?*

YesNo
Are you currently experiencing thoughts of harming others?*

YesNo
Are you currently experiencing a mental health crisis requiring immediate support?*

YesNo
Are you currently in immediate danger or feeling unable to keep yourself safe?*

YesNo
Important Safety Notice

Thank you for sharing this information. This form is not monitored continuously and is not designed for crisis support.

If you are in immediate danger or feel unable to keep yourself or others safe, please call 911 or go to your nearest emergency room.

You may also contact the 988 Suicide & Crisis Lifeline by calling or texting 988 for immediate support.
Are there any active legal matters related to custody, court involvement, CPS, or mandated treatment?*

YesNo
If you answered yes, please provide brief information on what those active legal matters are.
Preferred session times (select all that apply):*

Weekday morningsWeekday afternoonsWeekday evenings
Please provide at least 2-4 different times that you have available during the week for ongoing weekly therapy sessions?*
All sessions are conducted via secure telehealth. Do you have a private space and reliable internet for sessions?*

YesNo
Do you plan to use insurance that we are in network with for therapy?*

YesNo
If you plan to use insurance which provider?

Anthem Blue Cross Blue ShieldBlue Shield of CaliforniaOtherUnsure
If you plan to use insurance, what plan type do you have?

PPOHMOOtherUnsure
Subscriber Name: (If different from client)

First NameLast Name
Subscriber Date of Birth:

MonthDayYear
(If different from client)
Upload Insurance Card (Front of Card)

Cancelof
Upload Insurance Card (Back of Card)

Cancelof
Insurance Acknowledgement Checkbox

I understand that being in network with Anthem or Blue Shield of California does not guarantee coverage, authorization, or reimbursement for services. Insurance eligibility and benefits will be reviewed after the consultation if we move forward with services.
Do you have secondary insurance coverage?

YesNo
Which insurance is listed as primary for individual seeking therapy?
Upload Secondary Insurance Card (Front of Card)

Cancelof
Upload Secondary Insurance Card (Back of Card)

Cancelof
Please check each box to proceed
I understand that submitting this form does not establish therapy services.
I understand that a consultation does not guarentee ongoing treatment.
I understand that communication through this form is not monitored 24/7.
I consent to being contacted regarding scheduling and consultation follow-up.
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