Intake Enquiry Form

Please call or text 562-263-6041

We would want your enquiry process to be as smooth and efficient as possible. Please complete this form so we can direct you to a clinician that will best fit your needs.

When would you like to start therapy?

Please provide preferable day and time of the week that works best for you on a recurring basis.

Appointment Type:

TeleHealth Appointment In Person Appointment

Please select your insurance plan:

Member ID:

Group ID:

Are you the primary subscriber? If no, relationship to subscriber:

Primary Subscriber ID:

Primary Subscriber's Date of Birth:

Zip code listed with insurance company:

Are you seeking a specific modality of treatment? If so, please select:

Your Name

Your DOB

Phone

At this time our group practice does not offer psychiatry, medication management, one-time evaluations or crisis services. If you are in crisis, please go to your nearest ER or call 1-800-273-8255