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FOR MORE IMMEDIATE SERVICE, PLEASE TEXT OR CALL OUR FRONT DESK AT 951-387-4040 DURING NORMAL BUSINESS HOURS (M-F 730-630).

Location Preference for Sessions

Seen at the Riverside Office (Jesse Lane)

This will be for in-person sessions

Seen over Telehealth (Phone or Video Sessions)

This has the highest availability for booking a session soon

Client Name

Phone Number

Preferred Communication

Phone Call

Text Message

Preferred Therapist(s)

How will your sessions be paid?

Insurance Pay

(Kaiser and Optum only permit licensed therapists to provide care for their members)

Out of Pocket/Cash Pay

$200 Initial/$175 Standard Sessions ($100 for Pre-Licensed)

Out of Network/Therapist of Choice Isn't Listing My Insurance Carrier

(Note Insurance Below)

Comment or Question (Our receptionist reviews this form, please be mindful of disclosing therapeutic content)

This form will be sent to Talk Therapy Center's Receptionist/Administrative email. We will be getting back to you as soon as we are able. If you need more immediate service, please call 951-387-4040 during normal business hours (M-F 730-530).

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