Book Your Free Therapy Consultation

Name

Phone

Email

Date of Birth

Person completing form (e.g. mother, father, grandparent, legal guardian, physician, nurse, psychiatrist, etc.)

Are you a California resident? We are ONLY able to service CALIFORNIA at this time.

Yes

No

Which service are you interested in?

Individual Therapy

Group Therapy

If you are planning to use insurance for sessions, what type of insurance do you have? (Accepted insurance plans are listed below, choose self pay if N/A.)

Ins. Group Number

Member ID

Are you currently experiencing any of the following:* ***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 988 or visit your local emergency room.

Thoughts of hurting yourself or someone else

Active substance abuse

Legal issues

None of the above

If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here.

Are there any specific scheduling needs we should consider when setting up your appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ?

Preferred Therapist

Heather Cobbs, LCSW

Nina Aguirre, LCSW

Winter Villatoro, LCSW

Let's talk about it...

Let's Talk About It...

Contact us any time