Your Name* *
Your Email *
Your Best Phone Number* *
Location * Select Location of Sessions Beverly Hills Office Laguna Beach Office Phone Sessions Online Video Telehealth Sessions
Session Type Needed * Individual Therapy (Adults 18+) Couples 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)
Are You Hoping To Use Insurance? * No, I Do Not Want To Use Any Insurance (Out of Pocket ONLY) Yes, I Want To Use My Insurance (May Have An Annual Deductible & A Co-Pay; Please Verify With Your Insurance)
Do You Have An Insurance Co-Pay Yes (Usually Between $5 to $65 or more; Please Verify With Your Insurance) No (None in Rare Cases; Please Verify With Your Insurance)) Not Sure (Please Be Sure To Verify With Your Insurance)
Do You Have An Annual Deductible (Resets Jan 1st Each Year) Yes (Deductible Has To Be FULLY Met Each Year Before Insurance Starts Paying For Services; Please Verify With Your Insurance) No (Please Verify With Your Insurance) Not Sure (Please Verify With Your Insurance)
What is your Insurance Plan? * Aetna Anthem BlueCross (EAP & Medi-Cal Plans ONLY) Anthem Blue Cross Commercial Plans (Out-of-Network ONLY) Blue Shield (Not Blue Cross) Cigna HMC HealthWorks Humana (Out-of-Network ONLY) Kaiser (REQUIRES Prior Referral From Your PCP) Magellan Behavioral Health MHN MHNet PacifiCare (Out-of-Network ONLY) United Healthcare/Optum Other Insurance (Out Of Network ONLY) Private Pay - NO INSURANCE BILLING AT ALL
Your 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 *
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
Current Trend Of Top Concern * Improving Stable Worsening
How Long Have You Been Dealing With This Issue * Two To Four Week 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 * 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)
Who Referred You To Us: * 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 *
