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 is the best way to reach you?

Please enter your preferred form of contact: phone number or email address.

What conditions are you struggling with?

Obsessive-Compulsive Symptoms Anxiety or Specific Phobia Parenting Child With Anxiety Binge & Emotional Eating Compulsive Online Behavior 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

How did you hear about this therapy practice?

IOCDF Google/AI Search Provider Referred Psychology Today Other

Are you a member of Gold Coast Health Plan? I am in-network with Gold Coast and out-of-network with all other insurance plans. I can provide a superbill for you to submit to your insurance potential reimbursement.

No, I will pay out of pocket for therapy. Yes, I have Gold Coast insurance.

What is your preferred appointment time to meet on a standing weekly basis? Sessions are scheduled at the same time and day every week.

Morning: 9am-11am Midday: 12pm-2pm Late Afternoon: 3pm-4pm Flexible: I would like the first available.

Is there anything else you would like to share here or questions you would like to ask?

Optional: Feel free to share to anything that would be helpful for me to know prior to our 10-15 minute consult call. Sensitive details about your concerns should be reserved for the initial intake session.

Your information will be encrypted.