Name *

First Name

Last Name

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What services are you currently seeking? *

Individual therapy

Therapy for your child

Make Me Ok Program

Couples therapy

Family therapy

Have you ever been to therapy before? *

Yes

No

Do you prefer tele-health or in-person services? *

We will do our best to accommodate, however cannot guarantee in-person sessions.

In-person

Tele-health

No preference

We can only provide services to residents of the state of California. Are you a resident of the state of California? *

Yes

No

Are you currently prescribed a psychotropic medication? *

Yes

No

Services cost $300 - $800/month. Is this within your budget? *

Yes, I can afford $300-800/month.

I cannot afford $300-800/month but plan to use Superbills to cover services.

This is not within my budget. Please send me referrals for more affordable services.

If you have health insurance, who is your carrier? *

Not all insurance carriers are accepted at SRT and not all clinicians accept insurance.

United

Cigna

Kaiser

Anthem Blue Cross

Medi-Cal

Blue Shield of California

Aetna

Other

In order to access tele-health services, you will need internet and a smartphone or computer with speakers & a microphone. Do you have access to these needed items?

Yes

No

By checking this box, I agree to receive electronic communication regarding future services. *

I agree.

By checking this box, I agree to check my spam folder in the case I haven't heard back from Soco Rey Therapy within five business days. *

I agree.