Prospective Client Screening

9 Questions | HIPAA Compliant

Please correct the errors described below.

Welcome, what is your name?

What is your date of birth?

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

OCD and Related Disorders Specific Phobia Anxiety & Stress Internet Addiction Parenting Challenges 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 Ventura office Telehealth in California Hybrid/Flexible Unsure

How did you hear about this therapy practice?

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

Are you a member of Gold Coast Health Plan? I am in network with Gold Coast Health Plan and out-of-network with all other insurance companies. Clients with other insurance pay out of pocket and may submit superbills for reimbursement.

Yes No

What is your availability to meet on a standing weekly basis? Sessions are scheduled at the same time and day every week with 4pm as the latest option.

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 and emails are primarily for discussing logistics and answering questions about treatment approach. I am not able to give clinical advice or interpretations of symptoms over the phone or email.

Is there anything else you would like to share here?

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