Appointments | CIFT Counseling

We are here to support you through this season. To schedule a teletherapy appointment please complete and submit the form below and our team will contact you via email to schedule an intake session. If you are in crisis or need to see someone immediately, please call 911 or go to your nearest emergency room.

NOTE: If you are under the age of 18, please have a parent or guardian complete the form and submit it for you.

Name(s): (required)

Phone Number: (required)
If appointment is for a minor, please provide parent or guardian phone number.

Email: (required)
NOTE: Only enter 1 email address. If appointment is for a minor, please provide parent or guardian email.

Age(s): (required)

Date of Birth (MM/DD/YY): (required)

County of Residence: (required)

If other, what county do you live in?

APPOINTMENT INFO & AVAILABILITY
Type of session: (required)

If this appointment is for Couple's therapy, please provide the contact information (phone/email) for the additional party:

Preferred Format - hold control key to select more than one option: (required)

Best Day(s) - hold control key to select more than one option: (required)

Best Time(s) - hold control key to select more than one option: (required)

Preferred Location(s) - hold control key to select more than one option: (required)

THERAPIST PREFERENCES
Do you have a preference in your therapist's licensing/training status?

Preferred gender of therapist:

Preferred ethnicity of therapist:

My preference is:

FINANCIAL CONSIDERATIONS
We do not currently accept insurance (or MediCal) as a form of payment. Some health care plans, like PPOs, offer reimbursement for treatment from out-of-network providers. Please contact your insurance company to find out their reimbursement policy. CIFT does not work directly with any insurance or MediCal provider.

Do you have a budget for weekly counseling session?

If yes, what are you able to afford weekly?

Additional Comments Regarding Fee:

CLIENT HISTORY
Have you been in counseling/psychotherapy before? When?
Have you ever seen a therapist at CIFT? If yes, who did you see?
When was the last time you saw this therapist (year)?
Would you like to see the same therapist, if they are available?

Do you have any history or current substance use or abuse?

Is there a history of suicidality?

Please share with us the nature of your main problem: (required)

How serious does this problem feel to you? (required)
Please rate 1-5 (5=most serious)

How did you hear about us?

If you were referred by a church, please share which one:

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