Forms to Complete for Child Therapy
*A payment method on file will be required prior to placement
Step 1: Click this blue link to send a copy of your Photo ID and your child’s insurance card:
Step 2: Click the child intake button below
After completing all required fields, a blue “click to sign” button will appear which will secure the documents.
Do not download. The forms will be sent to us automatically after the “click to sign” button is pressed.
There is a 60-minute time-out limit.
A child intake from least one parent is required, but both parents are welcome to use the above link. If the second parent does not fill out an intake, please have them use the button below if they agree to the child’s treatment:
If you need help, please call (805) 642-4611 Monday through Friday from 9:00am to 5:00pm or send an email to [email protected].
Upon receipt of your completed forms, we will contact you with an appointment if we have an opening at the time your application is processed. If you do not hear from us within one week, it means that we were unable to find an appropriate appointment, and we do recommend continuing your search for a provider.
During the first 30 days, appointments are given on a ‘first come, first served’ basis by the date your documents are received. Please call our office at the beginning of each calendar month to update your continuing interest. Doing so moves your application to the current month’s list. Barring any insurance or treatment issues, those who contact us and have an intake on file longer than 30 days will be placed in an opening if one is available at the time of their call. Additional forms will be requested at the time of placement with a therapist.