Prospective Client Screening

Welcome, what is your name?

Please list the name of the prospective client. If client is a minor, please also list the name of an adult contact.

What is your date of birth?

Please list the DOB of the prospective client.

What conditions would you like help with? Please select all that apply.

OCD Anxiety & Phobias Emotional Eating & Binge Eating Internet Addiction Depression Other

Would you like to be seen in person or via Telehealth? Office is in Ventura, California. Telehealth is over secure Zoom and open to all CA residents.

In person therapy in Ventura Telehealth in California Hybrid/Flexible Unsure

How did you hear about this therapy practice?

IOCDF Psychology Today Google/AI Search Postpartum Support International ABCT Provider Referred Insurance Directory Other

Are you a member of Ventura County's Gold Coast Health Plan? I am in network with Gold Coast Health Plan. I do not bill any other form of insurance.

Yes, I have Gold Coast insurance. No, I don't have Gold Coast insurance. I will pay out of pocket for therapy.

What is your availability to meet on a standing weekly basis? Sessions are scheduled at the same time and day every week. There is no evening or weekend availability.

I am available from 9am to 2pm. I am only available for a 3pm or 4pm appointment. I would like the first available opening.

Please provide the email address and phone number where you would like to be contacted.

Consult calls are 10 minutes and primarily for discussing logistics and answering questions about my treatment approach. Detailed information about mental health challenges is shared in the formal intake session.

Is there anything else you would like to share here?

Optional: Feel free to share to anything that would be helpful for me to know prior to our consult call.

Your information will be encrypted.