Patient Registration

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Leavitt Marriage and Family Therapy

Expert Mental Health Counseling in California

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Email*

First name*

Last name*

Patient's Date of Birth *

Month

Day

Year

Who is filling out this form?*

Patient

Parent

Child

Partner

Friend

Other

Best Contact Number*

Patient's Home Address*

Briefly: what made you/the patient want to begin therapy?*

Are you seeking a particular type of therapy?*

Talk Therapy

CBT (Cognitive Behavioral Therapy)

DBT (Dialectical Behavior Therapy)

Trauma Therapy

EMDR (Eye Movement Desensitization and Reprocessing)

Couples Therapy

Family Therapy

Children's Therapy

Anger Management

Addiction Counseling

Grief Counseling

Unsure

Other

Are you seeking a particular type of therapist (i.e., any personal or professional characteristics)? *

Please upload a photo of the front of your insurance card for insurance verification. *

Please upload a photo of the back of your insurance card for insurance verification. *

If the picture of your insurance card is not uploading please share the following information:

1. Insurance company

2. Insurance ID

3. Group number

If the picture of your insurance card is not uploading please share the following information:

How did you hear about us? *

Google search

Alma

Psychology Today

Headway

Grow

Insurance referral

Good Therapy

Therapy Den

Other

Anything else you would like to share?

Contact Us

info.leavittmft@gmail.com

(310) 691-5647

Please click below to fill out the intake form

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