Prospective Client Screening

Pedroso Psychological Services, LLC

Dr. Daniella Pedroso

Thank you for your contact and interest in becoming a client. Please answer the following questions about yourself and the reason for seeking therapy at this time. The following questions should help me ascertain if we would be a good fit and that telehealth is an appropriate level of care for your needs.

Name and Date of Birth

Contact Information: Email and phone number

Please only enter the contact information that you feel comfortable being contacted on, even though the call back may come from a blocked/unlisted number for your privacy.. By entering this information, you consent to being contacted and to receive messages.

Please briefly describe what brings you into therapy now.

If Yes, what substances do you use? How much? How often? What's the date of last use?.

Are you pregnant or post-partum? Is your issue related to abortion, stillbirth, or loss of a child?

Enter your Insurance Plan Information, if applicable:

Please make sure that Dr. Pedroso is in-network with your plan prior to starting services by contacting them directly as we do not verify coverage.

By clicking this box and submitting this online form you understand this does not constitute an evaluation or a clinical or theraputic relationship. You understand you will be placed on a waitlist and that a preference for zoom may be contacted sooner due to availability, as in-person appointments may not be available. You also attest you are not in crisis, and that you are an adult completing the form for yourself. Do not submit an inquiry for someone else or minors. You also consent to be contacted by phone or email.

Thank you for taking the time to complete this secure online inquiry form.

Your information will be encrypted.