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For general questions, please use this form.
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What type of appointment would you like to schedule?* IndividualCouplesFamilyMinor (11-18)Minor (7-11)
Would you like to schedule for virtual or in person?* in personvideo appointmentseither
Your Name*
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Guardian Name(s) if client is under 18, N/A if 18+ - if for couples therapy provide partner's name*
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Your Insurance information* SHIPAnthem Blue Cross (not the same as Blue Shield)Medicare (not the same as Medi-Cal, or Medicare Advantage)Out of Network/PPOPrivate PayOther
Your insurance ID and group number (This helps us verify benefits. It may contain letters and numbers)
Please upload a copy of the front and back of your insurance card*
Patient Date of Birth*
Do you have a therapist preference? —Please choose an option—Brian Sedgeley, PsyDKristy Shanks, LCSWHelen Veazey, MAMarisa Gordon, LMFT
Additional information*