Abundance Therapy Center- Therapy Appointment Request

Are you a California Resident?* This field is required.

YESNO

Would you like to schedule for telehealth sessions or in-person sessions?* This field is required.

Virtual/Telehealth Sessions

In-Person Sessions

Either one works

What type of appointment would you like to schedule?* This field is required.

Individual Sessions (1 on 1)

Individual Sessions for Minor Aged 0-12 (Child)

Individual Sessions for Minor Aged 13-17 (Teen)

Couples Sessions

Family Sessions

Are you using insurance to pay for sessions?* This field is required.

Use my insuranceSelf-Pay

Select your insurance provider.* This field is required.Please select your PRIMARY insurance. If you have two insurances, you must verify which one is PRIMARY and select the PRIMARY to ensure sessions are covered. If your insurance is not listed, we are not in-network with your insurance. Please select Out of Network Benefits or return to the previous screen and select "Self-Pay".

Aetna

Aetna USC Student

Anthem Blue Cross HMO/PPO

Anthem Medi-Cal

Blue Shield PPO

Blue Shield Medi-Cal (Blue Shield Promise Health Plan)

Blue Shield Medicare

Cigna

Cigna EAP

Kaiser Permanente

LA Care Medi-Cal

Optum

Oscar

Evernorth

HealthNet/ MHN Commercial HMO/PPO

HealthNet/ MHN Medi-Cal

UC SHIP for Students

United

My insurance is not listed but I have a PPO plan and want to use Out of Network Benefits.

Aetna/ Aetna USC Student Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7AM - 11AM @ Anaheim

Weekday Afternoon 12PM - 4PM / Anaheim

Weekday Evening 5PM - 8PM @ Anaheim

Weekday Morning 7AM - 11AM @ Telehealth

Weekday Afternoon 12PM - 4PM / Telehealth

Weekday Evening 5PM - 8PM / Telehealth

Anthem Blue Cross/ UC SHIP Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7AM - 11AM @ Anaheim

Weekday Afternoon 12PM - 4PM / Anaheim

Weekday Evening 5PM - 8PM @ Anaheim

Weekday Morning 7AM - 11AM @ Telehealth

Weekday Afternoon 12PM - 4PM / Telehealth

Weekday Evening 5PM - 8PM / Telehealth

Anthem Medi-Cal Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7AM - 11AM @ Anaheim

Weekday Afternoon 12PM - 4PM / Anaheim

Weekday Evening 5PM - 8PM @ Anaheim

Weekday Morning 7AM - 11AM @ Telehealth

Weekday Afternoon 12PM - 4PM / Telehealth

Weekday Evening 5PM - 8PM / Telehealth

LA Care Medi-Cal Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

No availability

Cigna/Evernorth Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7AM - 11AM @ Anaheim

Weekday Afternoon 12PM - 4PM / Anaheim

Weekday Evening 5PM - 8PM @ Anaheim

Weekday Morning 7AM - 11AM @ Telehealth

Weekday Afternoon 12PM - 4PM / Telehealth

Weekday Evening 5PM - 8PM / Telehealth

Optum / Oscar / United Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7am - 11am / Los Angeles (KIDS UNDER 13 ONLY)

Healthnet/MHN Commercial HMO/PPO Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7am - 11am / Los Angeles (KIDS UNDER 13 ONLY)

HealthNet/MHN Medi-Cal Availability* This field is required.Our current availability based on your insurance is listed below. We do not have additional availability other than what is provided below. Please note that the selected time may or may not be available; we will do our best to accommodate your preferred times. We kindly ask that you select 2 or 3 options that will work for you. Thank you.

Weekday Morning 7AM - 11AM @ Anaheim

Weekday Afternoon 12PM - 4PM / Anaheim

Weekday Evening 5PM - 8PM @ Anaheim

Weekday Morning 7AM - 11AM @ Telehealth

Weekday Afternoon 12PM - 4PM / Telehealth

Weekday Evening 5PM - 8PM / Telehealth

Is the client 18 years or older?* This field is required.

YESNO

Parent or Legal Guardian's nameIf client is a minor.

Have you (or your child/partner) been hospitalized in the past 6 months due to psychiatric reasons?* This field is required.

YESNO

What was the reason and duration of hospitalization? When you were discharged, did you receive any treatment prior to today? Were you prescribed medications, and are you still taking them?

Have you (or your child/partner) had thoughts of hurting yourself or others in the past 2 weeks?* This field is required.

YESNO

Were these thoughts about hurting yourself or someone else? Did you or do you intend to act on these thoughts?

In the last 2 weeks, have you (or your child/partner) heard or seen things that were not really there?* This field is required.

YESNO

Can you explain what you heard or saw?

Are you (or your child/partner) currently dealing with any substance abuse, including alcohol?* This field is required.

YESNO

What substance was it? When was the last time you used it? How often do you use it? Are you currently in treatment or have you been in treatment?

What's bringing you to therapy?* This field is required.Select all that may apply.

Abuse

ADHD

Academic Stress

Anger Management

Anxiety

Autism Spectrum Disorder

Bipolar Disorder

Career/ Work Stress

Court Ordered Therapy

Chronic Illness/Pain

Cultural Issues

Depression

Eating Disorder

Grief/ Loss

Learning Disability

LGBTQIA+ Issues

Men's Issues

Mood Disorder

Non-Substance Addiction

Relationship Issues

Self-Esteem

Self Harm

Substance Abuse

Suicidal Ideation

Trauma/PTSD

Women's Issues

Is there anything else you would like us to know to help us match you with a best-fit therapist?Let us know if you are looking for specific modalities (DBT, EMDR, etc.), languages, have a particular therapist in mind, or have any other information that you want to note here.

Therapy Request FormWe need your information so that we can find the best possible therapist for you and get an estimate of your co-pay & benefits. If you are self-paying instead of using insurance, please enter "N/A" in the Insurance Member ID field. This form is secure and HIPAA-compliant. Please note that if you are using insurance, we require your member ID to verify eligibility and benefits. If you have two insurances, you must verify which one is your PRIMARY INSURANCE and provide us with your PRIMARY INSURANCE to ensure sessions are covered.

Client's Legal Name

Phone #

Email Address

Insurance Provider

Insurance Member ID

Client's Birthdate

Couples Therapy Disclaimer & Notice of Fees* This field is required.We cannot usually accept insurance for couples therapy, because insurance companies usually only cover treatments that are seen as medically necessary. Our fees for couples therapy are $145-$190 per session, depending on the therapist you and your partner work with.

I have read the information presented above. By filling out the next form, I understand and acknowledge that I will not be able to use insurance for my couples therapy. Payment shall be made using a credit, debit or HSA card.

Couples Therapy Request FormPlease enter both partners' contact information and availability. This form is secure and HIPAA-compliant.

Partner #1, Legal Name

Partner #2 Legal Name

Partner #1, Phone Number

Partner #2, Phone Number

Partner # 1, Email

Partner # 2, Email

What time of the week are you both typically free ? (ex. weekday mornings, afternoons")

At this time Abundance Therapy Center's clinical staff are licensed to provide services only to California residents. Please visit https://www.psychologytoday.com/us to find a licensed therapist in your state.

We understand how difficult it can be to find a therapist when you need one most. Unfortunately, due the overwhelming demand for mental health services caused by COVID-19 all available times with therapists who accept your insurance type are currently booked up! We do recommend reaching out if you want another practice recommendation or have any other questions about what we offer here at Abundance Therapy Center. Our team truly regrets any inconvenience this may cause.* This field is required.If you would like a list of referrals please enter your name and email address. One of our care coordinators will email you with referral options.

Name

Email Address