Intake Form For Prospective Clients of Psychotherapy Services

Please be assured that the information you provide will only be used to help identify appropriate therapy services for you, and will be kept strictly confidential.

First name

Last name

Enter City Here

Enter Zip Code Here

Phone

OK To Leave Message

Age

Sex Assigned At Birth

Gender

Race/Ethnicity

Pronouns

I Am Seeking

Reason(s) you are now requesting therapy services from North County LGBTQ Resource Center

Have you been in therapy previously?

Do you have insurance?

Is your insurance Medi-Cal?

If you receive Medi-Cal, what is the name of your health plan?

If not Medi-Cal, what is the name of your insurance?

NOTE: At this time, North County Center does not take any insurance. If you have insurance, we can help you connect with a provider that can assist you.

North County Center offers services at low to no cost. In order to keep this service sustainable, we rely on you and your best judgment regarding how much you will be able to pay for your therapy sessions.