Referrals

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Therapy Request Form

Please provide the following information to initiate services. If you plan to use insurance, gather your insurance details to speed up the process. A team member will contact you within 5 business days. This form is encrypted for security.

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Client's first & last name *

Client phone number *

Client's email address *

Physical address with ZIP code (for emergency purposes) *

Client's date of birth *

Age of client *

Contact person (if different than above)

Type of therapy *

Individual Therapy Child or Adolescent Therapy Couples Therapy Psychological Testing Group Therapy

Therapy preference *

Online In-person

If in-person, which office location do you prefer?

La Mesa, CA El Centro, CA Online

Is there a particular therapist you'd like to see? (Write 'None' if not)

Why are you seeking therapy? *

How are you paying for services? *

Self Pay Insurance Victim of Crime (CalVCB)

Your current insurance provider (if using insurance)

Insurance details: name, policy holder, member ID#, and insurer phone (or write N/A if self-paying)

For couple/family therapy, list each person: full name, phone, email, address, gender, DOB (or N/A)

How do you identify? *

Male Female

How did you hear about us?

Comments

Ready when you are

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Request an appointment and a team member will follow up to match you with the right therapist.

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