Name *

First Name

Last Name

Preferred Method of Contact(s) *

Select all that applies.

E-mail

Text Message

Phone Call

Will You Be Utilizing Your Insurance? *

Yes

No

Select Day(s) That Work Best for You *

It is not guaranteed that these days will be available.

Monday

Tuesday

Wednesday

Thursday

Saturday

I am Flexible

Select Time(s) That Work Best for You *

It is not guaranteed that these times will be available

Mornings (10 AM, 11 AM, 12 PM)

Afternoons (2 PM, 4 PM, 5 PM)

I am Flexible

Have you had any suicidal thoughts, plans or attempts in the last month? *

If you are experiencing a life-threatening emergency, please get in touch with 911. If you require immediate assistance, please get in touch with your local county crisis hotline. For Orange County: 1-877-727-4747, Los Angeles: 1-800-854-7771.

Yes

No

Have you ever been psychiatrically hospitalized in the past 5 years? *

Yes

No

Any current or past issues with alcohol or drug abuse? *

Yes

No