Family Therapy

Client Information

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

Postal code *

Family Members Participating in Therapy

Please list each family member who will be participating in therapy. If they are an adult, please include their phone number and email for consent.

Family Member 1

First Name 1:

Last Name 1

Date of Birth 1

Phone Number 1

Email Address 1

Family Member 2

First Name 2

Last Name 2

Date of Birth 2

Phone Number 2

Email Address 2

Family Member 3

First Name 3

Last Name 3

Date of Birth 3

Phone Number 3

Email Address 3

Family Member 4

First Name 4

Last Name 4

Date of Birth 4

Phone Number 4

Email Address 4

Court-Ordered Therapy

Is your therapy court ordered? *

Yes – Family Law Cour

Yes – DCFS

Yes – Probation

If yes, please upload your court documents

Therapy Needs & Preferences

Briefly describe the issue you would like to work on

Are there any specialties you are interested in?

Insurance Information

Primary Insurance Provider *

Primary Subscriber *

Self

Spouse

Parent

Primary Subscriber’s Name *

Primary Subscriber’s Date of Birth *

Primary Insurance Member ID *

Secondary Insurance Provider

Secondary Insurance Member ID

Upload front and back of insurance card

Referral Information

How did you hear about us?

If Other, how did you hear about us?

Appointment Preferences

Preferred Location *

Lancaster Office

Valencia Office

Tehachapi Office

Would you prefer In person or Telehealth Appointments? *

In Person

Tele-Health

Either will work

Preferred Appointment Time *

Best Way to Contact You *

Additional Information

Is there anything else you would like us to know?

Email Risk Acknowledgement and Use Consent

I understand that the use of email and SMS text messages is inherently insecure and poses a risk to the security and confidentiality of my protected health information. I consent to communication via email or text.

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