First Name
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Last Name
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Email
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Phone
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Date of birth
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Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking:
Any questions or additional information we should know:
We can only provide services in the state of California. Check here to confirm you reside in California:
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Yes, I/we reside in California.
We are mainly a self-pay office but some of our therapists are able to accept some Medi-Cal insurance plans. Are you a self-pay or Medi-Cal client?
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Self-pay
Medi-Cal
If using Medi-Cal, please upload a copy of the front and back of your insurance card.
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