Thank you for your interest in working with a Rose Wellness Therapist!
Please note, that it may take our intake/ admin a few days to return your inquiry. Thank you for your patience.

Privately Paying Clients-We accept those that are privately paying for services. Those that choose to go out of network can request a "superbill" that they can submit for potential reimbursement to their insurance.

 If you are looking to go through your insurance please read the following information.

Insurance- We are in network with the following:

  • Cigna, Cencal, Healthnet medi-cal, Anthem UCSHIP, Regular Anthem Plans, Aetna, Cal Viva (medi-cal), CA health and wellness (medi-cal), Healthnet/ MHN Commercial (licensed only), United Healthcare/ Optum UBH

Your responses will be stored in our HIPAA compliant and private platform and reviewed by our intake specialists.  Please fill this form out in it's entirety so that we can match you with the therapist that would be the best fit for you!

IMPORTANT- Please make sure to provide us with ALL of your insurance information. When clients fail to provide us with complete insurance info (even if it is a primary or secondary policy) it leaves them vulnerable to large balances. Insurance plans have deadlines for submitting claims and if we don't have your correct policy(s) you run the risk of your insurance denying the claims if they are past the deadline.

If you are under 26 years old- please make sure to double check with any parents/ guardians if they have you listed on their insurance policy.

  • Myself
  • Myself and my partner (couple's therapy)
  • My Teenager/adolescent (ages 13-17)
  • My child (ages 0-12)
  • A child, but I am not the guardian
  • A teen, but I am not the guardian
  • Someone else
  • No elements found. Consider changing the search query.
  • List is empty.
  • A friend
  • A current client
  • Psychology Today
  • Google Search
  • Another Professional
  • Instagram
  • UCSB/ CAPS
  • Flyer
  • School
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
Please check all that apply

Client Information

-Please enter the information for the person you are requesting services for

-If requesting services for yourself, fill out with your information

First, Last
  • Female
  • Male
  • Non-binary / gender non conforming
  • Two Spirit
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
Or primary contact phone # if filling out for a minor
You can text STOP to unsubscribe at anytime
Or primary contact email if filling out for a minor
____ Years old
  • Yes
  • No
  • Unsure
  • Prefer not to say
  • No elements found. Consider changing the search query.
  • List is empty.
Ex: She/Her
  • English
  • Spanish
  • English and Spanish
  • French
  • Portuguese
  • Armenian
  • Vietnamese
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
  • Female
  • Male
  • non-binary/ gender non-conforming
  • Two spirit
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
We use this to send assessments to track your teen's progress in therapy!

Therapy Preferences

  • No, I'm open to suggestions on the best fit
  • Yes, but I'm open to working with others
  • Yes, and I'm not open to working with others
  • No elements found. Consider changing the search query.
  • List is empty.
Let us know if you've had any previous successful therapy and what made it successful.
  • Binary Breakers Teen Group (teens, Remote Wed 6-7pm)
  • Parent Support Group -Navigating difficult emotions- (parents of children ages 3-8 yrs old, In person) Thursdays 12:15-1:30pm in person
  • Minorities in STEM (college students in person) Time TBD
  • TeenWell DBT Group (teens ages 13-17 yrs old, in person)- Mondays 4-6pm
  • No thank you, I'm not interested in any groups at this time
  • I would be, but I don't see one that fits!
  • No elements found. Consider changing the search query.
  • List is empty.
  • In person only
  • Telehealth/ Remote
  • Hybrid
  • First available
  • No elements found. Consider changing the search query.
  • List is empty.
Please let us know if you have a preference for telehealth or in person
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • Maybe
  • No elements found. Consider changing the search query.
  • List is empty.

Availability for Regular Appointments

Our appointments are regularly scheduled at the same day and time each week. Please check the boxes for each possible timeslot that you would have weekly availability. Filling this out will help us match you more quickly!

Guardian Information (Skip if client is over 18)

If client is under 18 years of age, enter guardian information below.

  • Yes, I am married to the other guardian/ parent
  • Not married to other parent but I have full custody
  • No, Custody is shared and there is a custody order
  • No, Custody is shared but there is no official custody order
  • No, I am a non-custodial parent
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
  • Yes
  • No
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.

Insurance Information

Primary Insurance (Skip if N/A or not using insurance)

If filling out for a minor- please put their insurance coverage here

Once you are scheduled for a consultation with a therapist, we will check your benefits with your insurance. Verification of benefits is a courtesy and not a guarantee of coverage. If your insurance does not cover services, you will be responsible for the amount owed each session. It is important for you to be proactive in knowing your insurance benefits. We encourage you to call your insurance representative using the member service number on the back of your card to verify this information for yourself. The insurance payor has final say on claims submitted on your behalf including any copay, coinsurance, or deductible amounts that may be owed.

  • Yes, I am covered under ONE insurance plan
  • Yes, I am covered under TWO insurance plans
  • No, I would like to opt out of using insurance- OR your practice is out of network with my insurance
  • No elements found. Consider changing the search query.
  • List is empty.
If filling out for a minor put their insurance coverage here
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
  • Aetna
  • Anthem/ Blue Cross
  • Cigna /Elevance
  • Anthem UCSHIP (for students)
  • Cencal
  • Healthnet Commercial (through employer)
  • Healthnet Medi-cal (cal viva, CA health and Wellness)
  • United/ Optum
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
  • Client themselves
  • Primary Subscriber is client's spouse
  • Primary Subscriber is Client's parent/ guardian
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.

Secondary Insurance Info (Skip if N/A or not using insurance)

  • Aetna
  • Anthem
  • Anthem UCSHIP (for students)
  • Blue Shield of CA
  • Cencal
  • Cigna/ Evernorth
  • Healthnet/ MHN Commercial
  • Healthnet Medi-cal
  • United/ Optum
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
  • Client themselves
  • Client's spouse
  • Client's Parent/ Guardian
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
If you don't have a CAPS referral yet, please continue to submit form and reach out to - [email protected] to request one. Once received you can email it to [email protected]. The sooner we have this the more quickly we can get you services!
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