Call Us: (562) 263-6041
1. When would you like to start therapy?
2. Please provide preferable day and time of the week that works best for you on a recurring basis. Appointment Type: TeleHealth AppointmentIn Person Appointment
3. Please select your insurance plan: —Please choose an option—AetnaOptumUnitedCignaCarelon
4.Member ID:
5. Group ID:
6. Are you the primary subscriber? If no, relationship to subscriber: I am the Primary SubscriberChildParentSpouseOther
7. Primary Subscriber ID:
8. Primary Subscriber's Date of Birth: 202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190312345678910111212345678910111213141516171819202122232425262728293031
9. Zip code listed with insurance company:
10. Are you seeking a specific modality of treatment? If so, please select: Cognitive Behavioral TherapyInternal Family SystemsEMDRDialectical Behavioral TherapySolution Focused TherapySupportive counseling
11. Your name
12. Your Date of Birth: 202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190312345678910111212345678910111213141516171819202122232425262728293031 13. Your email:
14. Your Phone Number:
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