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Book a consultation

Let's Talk About It...

Home
About
- Our team
- Careers
Services
- Group Therapy
- Individual Therapy Services
FAQ
Blog
Learn

Book a free consultation

New Client Submission Form

Contact us any time

Name

Phone

Date of Birth

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

What state are you located in?

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.)

Aetna

Anthem Blue Cross of California

Kaiser Southern California

Optum

Self Pay

United

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

Thank you for completing the form. We appreciate your interest in our services.

You will be redirected to schedule your free 15-minute consultation shortly. If you are not redirected click here.

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(213) 770-3388

support@ihearttherapy.com

22543 Ventura Blvd #219 Woodland Hills, CA 91364

Book a free consultation

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- Our team
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- Group Therapy
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