Name *

Please enter the name of the person who would be receiving care.

First Name

Last Name

Checkbox *

I am filling this form out for my own care

I am filling this form out for someone else's care

Phone *

(###)

###

####

What services are you looking for? *

Please select any that apply to you

Medication Management

In Person

Telehealth/Video Calls

What brings you to us? *

Please select any that apply to you

Anxiety

Attachment Issues

Depression

Family Issues

Addiction/Recovery

Grief/Loss

ADHD

Life Stressors

Relationship Issues

Trauma

Work Stress

Other- Please Describe Below

What insurance do you have? *

Anthem Blue Cross

Blue Shield of California

Partnership Health Plan / Medi-Cal

Lyra

Medicare

United Health Care/Optum

Self-Pay (No Insurance)

None of the above

Please Provide your Date of Birth *

MM

DD

YYYY

What is your availability for care? *

Mornings

Afternoons

Evenings

Weekends

Weekdays

Flexible (May result in quicker placement)

Follow up

Please check this box if you would like to have a brief conversation with our intake specialist

Agreement *

Please click here to verify that you understand that this form does not guarantee services.