Consultation Request Form

Dr. Sabrina Stutz, PhD

Licensed Psychologist

admin@drsabrinastutz.com

www.drsabrinastutz.com

(949) 541-7972
Consultation Request Form:

If you would like to book a consultation with Dr. Sabrina Stutz, PhD, Licensed Psychologist, please complete the following information form. After you submit your form, you will receive an email or text letting you know if your requested time-slot is available and how to schedule your free 15-minute phone consultation. If your time-slot is not available, you will receive an email asking if you'd like to remain on the waitlist to be contacted if/when your preferred time-slots become available. Because of the nature of therapeutic work, it is rare that we can confirm a specific length of time you may be waiting. We are now accepting new clients for Saturday appointments. Availability for Wednesday and Friday appointments is limited. Tuesday and Thursday morning appointments will be available beginning September 2025.
Name of Adult or Responsible Caregiver*

First NameLast Name
Name of Child Client (if applicable)

First NameLast Name
Age of Client (if for a child, write child's age)*
US State of Residence*
This is the state you will be in when receiving telehealth services
Time Zone
What time zone do you live in?
Phone Number*
E-mail*
example@example.com
What type of therapy/program are you interested in?*

PCIT Toddler (ages 1 month to 36 months+)Parent Child Interaction Therapy (PCIT) (ages 3-7)PCIT Older Child (ages 7-10)PCIT CALM (for anxiety, ages 2-10)PC-CARE (ages 1 to 10)Diabetes-Informed TherapyMedical Concern Related TherapyOther
How did you hear about us?*
Please Specify*
Scheduling Availability

Dr. Sabrina Stutz, PhD has a small, boutique-style psychotherapy practice with limited availability. By limiting the number of active clients at any given time, she is able to offer each client more comprehensive and personalized care including unique-to-you handouts, weekly summaries and action plans, and visual progress tracking. Typically, clients are assigned a weekly time slot that both they and Dr. Stutz commit to so as to create stability and reliability in the therapeutic experience.

Please mark any times that may be options for therapy appointments for you. The more flexibility in scheduling, the more likely a slot that matches your needs will become available sooner.

**Please note, options below reflect the most current schedule. If you do not see an option that matches your schedule, unfortunately, we do not anticipate a slot that matches your needs to become available. Other weekdays, weekends, and evening times are not currently available.
Availability For Appointment Times*

Tuesday mornings **starting in September 2025 (9am-12pm)Wednesday afternoon (1pm-5pm)Thursday mornings **starting in September 2025 (9am-12pm)Friday afternoon (1pm-5pm)Saturday mornings (7am-10am)Saturday midday (11am-2pm)Saturday afternoon (3-5pm)
Telehealth Therapy Services Only:

Dr. Sabrina Stutz, PhD offers telehealth therapy only into California, North Carolina, and all 40+ PSYPACT States.
I understand that Dr. Sabrina Stutz, PhD does not offer in-person therapy at this time.*

Yes, I understand.No, I do not understand.
Out of Network Provider:

Dr. Sabrina Stutz, PhD is considered an "out-of-network provider" for insurance companies. This means, clients pay full rate at the time of service, and then have the choice of whether or not they would like to submit their receipt of services (a superbill) to their insurance company to request partial reimbursement from them directly according to their plan's out of network benefits. Please review the website at www.drsabrinastutz.com/fees-insurance for current rates.
I understand that Dr. Sabrina Stutz, PhD does not accept any insurance payments, directly.*

Yes, I understand.No, I do not understand.
I understand that Dr. Sabrina Stutz, PhD is not accepting new clients with high risk needs (e.g., suicidal thinking or gestures), court-ordered therapy, or child-welfare reunification plans.*

Yes, I understand.No, I do not understand.
(Please mark all that apply) If a slot opens, I give permission for Dr. Sabrina Stutz, PhD to contact me and leave a message identifying herself via:*

EmailPhone callText
Other Important Information:
Do NOT submit personal, clinical information or symptoms here. This is not a HIPAA compliant platform. You do not yet have a therapeutic relationship with Dr. Sabrina Stutz, PhD, and therefore information you share is not protected by therapist-client privilege.
Please verify that you are human*
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Consultation Request Form: