Prospective Client Screening

HIPAA compliant form

Please correct the errors described below.

What condition would you like help with?

OCD Anxiety Depression Compulsive Internet Use Parenting Challenges Trichotillomania (hair pulling) Excoriation Disorder (skin picking) Other

Are you seeking help for yourself or someone else?

Self Child (minor) Child (adult) Family Couple Patient

Are you available for weekly therapy on Mondays, Tuesdays or Wednesdays?

Yes No

Would you like to be seen in person or via Telehealth?

In person- Ventura office Telehealth- I live in California Hybrid / Flexible Unsure

How did you hear about this therapy practice?

Psychology Today International OCD Foundation Postpartum Support International Association for Behavioral & Cognitive Therapies Provider Referred Google Search Insurance Directory Other

Please write in the name of your insurance and secondary insurance, if applicable.

Please list the best email and/or phone number to contact you.

What is your name?

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Teva Johnstone, Licensed Therapist

teva@therapyemail.com

Teva is a Psychotherapist and Licensed Clinical Social Worker in California specializing in OCD and related conditions. She offers in person ERP treatment in Ventura and Santa Barbara Counties and online therapy throughout the state. *CA LCSW #103826

tevajohnstonetherapy.com

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