Name *

First Name

Last Name

Phone *

(###)

###

####

How were you referred to our center?

Friend/Family member

Church/Pastor

PLNU

Other, please specify in Additional Comments

Which office location would be most convenient for you?

Carlsbad

Chula Vista

Coronado

Escondido

Lakeside

La Mesa

Mission Valley

Oceanside

Rancho Bernardo

Spring Valley

Does not matter

Which of the following are you interested in seeing?

A Licensed Doctoral-level Therapist or Psychologist $225.00 for a 55-minute session

A Licensed Therapist $210.00 for a 55-minute session

A Registered Associate Therapist or Psychological Assistant $195.00 for a 55-minute session

A Point Loma Nazarene University Masters of Arts in Clinical Counseling Therapist-In-Training student $10 per 55-minute session. You must consent to being audio and video taped for instructional purposes.

Any of the above

Would you like us to bill your health insurance?

We are able to bill any PPO insurances as an out-of-network provider. We are in-network providers for Medicare Part B, Tricare, and TriWest (VA) ONLY. If you have an insurance plan with out-of-network benefits, we can bill your insurance as a courtesy to you. To verify if you have coverage for our services, call the customer service number on your insurance card. Be sure to bring any insurance information with you when you come in for your first appointment.

Yes, I have PPO insurance.

Yes, I have Tricare insurance. (AD service members must have a referral prior to first visit)

Yes, I have TriWest VA insurance. (authorization from the VA is required for our services to be covered)

Yes, I have Medicare Part B insurance. (Advantage Plans or Medicare Replacement Plans do not cover our services)

No, I cannot bill my insurance/do not have insurance.

Is there a specific specialty you are looking for?

Anxiety

Depression

Grief

Trauma

Premarital Counseling

Couples/Marriage Counseling

Family Counseling

Teens

EMDR

Other, please specify in Additional Comments

What is your gross monthly household income?

Please fill this portion out only if you wish to see a Registered Associate and would like to see if you qualify for a fee reduction due to financial limitations.

$0-$1500

$1,501-$2,500

$2,501-$2917

$2918-$3,333

$3,334-$3,750

$3,751-$4,167

$4,168-$4,583

$4,584-$5,000

$5,001-$5,417

$5,418-$5,833

$5,834-above

How many are in your family?

Please fill this portion out only if you wish to see a Registered Associate and would like to see if you qualify for a fee reduction due to financial limitations.

1 or 2

3 to 5

6+