Your Name* *
Your Email *
Your Personal Mobile Phone Number* *
Location of Sessions * Location of Sessions Phone Sessions - California Online Video Telehealth Sessions - California Phone Sessions - Florida Online Video Telehealth Sessions - Florida
Session Type Needed: * Please Select Individual Therapy (Adults 18+/Provider MUST also be IN NETWORK with your insurance for sessions to be covered by your policy) Couples Therapy (Not Covered By All Insurance Plans) Group Therapy (Not Covered By All Insurance Plans) Employee Assistance Program (EAP From 3 to 12 Sessions Depending On Your Plan - REQUIRES Pre-Authorization # From Your Employer BEFORE Making An Appointment)
Are You Hoping To Use Your Insurance? * Please Select No, I Do Not Want To Use Any Insurance (100% Out of Pocket ONLY & CANNOT Be Back Billed If You Change Your Mind - ONLY Moving Forward & You Have To Notify Us IN WRITING Of This Change)) Yes, I Want To Use My Insurance (May Have An Annual Deductible & Most Have A Co-Pay For Each Session; Please Be Sure To Confirm Your Coverage Independently With Your Insurance) Yes & I Also Have Secondary Insurance (May Have An Annual Deductible & Most Have A Co-Pay For Each Session; Please Be Sure To Confirm Your Coverage Independently With Your Insurance) For Florida, we are not currently accepting insurance at this time
Do You Have An Insurance Co-Pay? (Most Plans Do & You Are Responsible To Know & Confirm Your Coverage With Your Insurance) * Please Select Yes (Usually Between $5 to $65 or more; Please Be Sure to Confirm Your Coverage Independently With Your Insurance) No (None in Rare Cases; Please Be Sure Confirm Your Coverage Independently With Your Insurance) Not Sure (Please Be Sure To Confirm Your Coverage Independently With Your Insurance)
Do You Have An Annual Deductible? (Resets Jan 1st of Each Year & You Are Responsible To Know & Confirm Your Coverage With Your Insurance) * Please Select Yes (Deductible Has To Be FULLY Met Each Year Before Insurance Starts Paying For Services; Please Confirm Independently With Your Insurance) No (Please Confirm Independently With Your Insurance) Not Sure (Please Confirm Independently With Your Insurance)
Which Insurance Plan Do You Have? * Please Select Aetna Anthem BlueCross (EAP & Medi-Cal Plans ONLY) Anthem Blue Cross Commercial Plans (SCA) Blue Shield (Not Blue Cross; Policies Based Outside of CA ONLY) Cigna HMC HealthWorks Humana (Out-of-Network ONLY) Kaiser (HMO - REQUIRES Prior Referral From Your PCP & KAISER Authorization BEFORE Making An Appointment) Magellan Behavioral Health ( CA Blue Shield Plan Mental Health Administrator) MHN MHNet PacifiCare (Out-of-Network ONLY) United Healthcare/Optum Other Insurance (Out Of Network ONLY) Private Pay - NO INSURANCE BILLING AT ALL
Your Complete Date of Birth: *
Are You The Primary Policy Holder? * Please Select Yes No
First & Last Name of Primary Policy Holder: *
DOB of Primary Policy Holder: *
What Is Your Current Top Concern? * Please Select Adjustment Disorder Adult ADHD Anger Management Anxiety Anxious Attachment Assertiveness Bereavement/Grief Counseling Bipolar Disorder Body Image Issues Break-Up/Divorce Career Counseling Cognitive-Behavioral Therapy (CBT) Coping Skills Dating/Relationship Readiness Depression Difficulty Sleeping/Insomnia Eating Disorders Emotional Eating and Binging Family Issues Feeling Stuck Gender Dysphoria Getting Organized Grief Group Therapy Ineffective Communication Infidelity Internet Addiction Irrational Fears/Phobias LGBTQ/Gender Spectrum Concerns and Sexuality Life Coaching Life Transitions Loneliness Marriage Counseling Men's Issues Mindfulness Mood Swings Negative Self-Talk Obsessive-Compulsive Disorder (OCD) Panic Attacks Parenting People Pleasing Phobias Poor Boundaries Post-Traumatic Stress Disorder (PTSD) Postpartum Depression Self Esteem Self-Destructive Behaviors Sexual Abuse Counseling Sexual Dysfunction Sexual Performance Anxiety Sleep or Insomnia Social Anxiety Spirituality Stress Management Stress/Burnout Substance Addictions Trauma Women's Psychological Issues Work Related Counseling Worry
What Is The Current Trend Of Your Top Concern? * Please Select Improving Stable Worsening
How Long Have You Been Dealing With Your Top Concern? * Please Select Just A Few Days About A Week or Two Two To Four Weeks One To Three Months Three To Six Months Six Months To A Year Two To Five Years Five to Ten Years The Majority of My Adult Life Since Childhood My Entire Life
Are You Currently Experiencing Any Suicidal/Self-Harm Thoughts? * Please Select No, Never Have At Any Point In My Life Yes, I Did When I Was Younger (No Longer An Issue) Yes, I Have Passive Suicidal Thoughts Now (No Actual Plan To Carry It Out) Yes, I Have Active Suicidal Thoughts (Please Dial 911 NOW Or Go To Nearest Hospital Immediately)
How Would You Describe Your Usual Conversational Style? * Please Select Talkative & Easily Engaged Shy Yet Willing To Make A Genuine Effort To Be Open & Engaged Shy, Reserved & Mostly Quiet
Who Referred You To Us? * Please Select Self My Partner/Family/Friend Another Client In Our Practice My Google Search My Insurance Panel My Physician My Psychiatrist UCLA (Westwood) Cedar Sinai Hospital (Beverly Center Area) Hoag Hospital (Newport Beach) Mission Hospital (Laguna Beach) Other
Comment or Message *
