How To Book Therapy

BEHAVIORAL HEALTH SERVICES

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?

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.

Are you able to pay for your therapy sessions per our affordable sliding scale that ranges from $25- $60 per session?

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.