Weekly video sessions available for individuals up to the age of 60:

Tuesdays @ 12pm + 3pm + 4pm

Wednesdays @ 12pm + 3pm + 4pm

Thursdays @ 4pm

I celebrate the LGBTQIA+ community and honor transgender individuals

Name

First Name

Last Name

Phone

(###)

###

####

Phone Consultation Type

CA resident: Insurance: Weekly video sessions

CA resident: Private pay: Weekly video sessions

OR resident: Insurance: Weekly video sessions

OR resident: Private pay: Weekly video sessions

Date of Birth

Legal Name

Private Pay: Type N/A

Insurance Network Name

Private Pay: Type N/A

Member ID/EAP Auth #

Private Pay: Type N/A

Address

Group #

EAP/Private Pay: Type N/A

Referral Source

Preferred Available Video Session Time Option (see top of page):