Contact Us Interested in Becoming a Client "*" indicates required fields New or Returning Client?* New Returning Name* First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Address* Street Address City ZIP / Postal Code Phone Number*Email* Preferred Contact Method* Email Phone Either Type of Therapy* Adult Couple Family Child/Adolescent Premarital Psychological Assessment Therapist Gender Preference* Male Female No Preference Reasons for Seeking Therapy*Insurance Carrier / Payment Type* Aetna PPO Client Access Program (CAP) Self Pay Lawndale Christian Health BlueCross BlueShield PPO Other Submit Front Proof of Insurance*Max. file size: 100 MB.Submit Back Proof of Insurance*Max. file size: 100 MB.To expedite the process of scheduling an appointment, please upload a photo of the front and back of your insurance card for us to have on file.Appointment Availability (Check All That Apply) Mornings: 9am - 12pm Afternoons: 12pm – 4pm Evenings: 4pm – 9pmMondays Mornings Afternoons Evenings Tuesdays Mornings Afternoons Evenings Wednesday Mornings Afternoons Evenings Thursdays Mornings Afternoons Evenings Fridays Mornings Afternoons Evenings Saturdays Mornings Afternoons Evenings CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Please Get in Touch for Additional Details
