Get Started Today

Please fill out this form to request services for yourself or anyone else you believe will benefit from our services.

Our staff will get in touch with you within 48 hrs to understand your needs and personal preferences. You'll be matched with the best therapist to support your wellness journey.

If you have any questions or concerns, please call us at (818) 330-3337

Or write to us to [email protected]

We're here to help!

Contact Information

Full Name *

Date of birth *

Phone Number *

Email Address *

Preferred Contact Method *

Phone

Email

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Address

Street Address *

City *

State *

Country

Postal Code *

What Service Are You Interested In?

If Case Management or Other Specify:

Payment Method

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Insurance

Insurance Information

Policyholder’s Name: *

Relationship to Client: *

Insurance Provider: *

Member ID: *

Group Number (if applicable): *

Please Upload Your Insurance Card

If you can't upload the image please email it to us at [email protected]

Preferred Appointment Days/Times

Referral Source

Additional Notes or Concerns

Emergency Contact

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Phone Number

Relationship to client:

Authorization

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