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Intake Screener
Name
First
Last
Phone
(Required)
Email
(Required)
Calling for:
Self
Spouse or Partner
Child
Friend
Sibling
Parent
Other
Name of client if not calling for self
Untitled
(Required)
Client location
Preferred office location *
(Required)
West LA
Encino
Either
This is for after the shelter in place is lifted and it's safe to go into the office.
Primary condition *
(Required)
OCD
Tics/Tourettes
Hoarding
Trichotillomania (hair pulling)
Dermatillomania (Skin picking)
Body Dysmorphic Disorder
Generalized Anxiety Disorder
Health Anxiety
Panic disorder/Panic Attacks
Specific Phobia
Emetophobia
Social Anxiety
ADHD
Autism co-morbid with one of the above
PTSD/Trauma
Life Stressors
Other
Please specify*
(Required)
Previous Therapy
(Required)
Yes
No
Primarily interested in: *
(Required)
Individual therapy in person (Please note that due to Coronavirus, we are only meeting with clients via teletherapy at this time)
Individual therapy online (Please note we are only licensed in CA and can only provide teletherapy in CA)
Family therapy
Couples therapy
One-time Consultation
Please note at this time we are only providing online therapy until it is safe to meet in person.
Therapist preference:*
(Required)
Male
Female
First availabalble
We have multiple therapists who work at Anxiety Therapy LA. For more information about our therapists please see https://anxietytherapyla.com/meet-our-team.
Preferred day of the week (Check all that apply)*
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred time of day (Check all that apply)*
(Required)
Morning
Afternoon
Evening
Flexible Schedule
Depends on the day
How did you hear about us? (If another clinician or doctor referred you, please list name in OTHER)
IOCDF website
TLC for BFRBs
ABCT
Psychology Today
Therapy Den
SPACE
Google
Other Online location
Another therapist
My doctor
My psychiatrist
Other
Please specify*
(Required)
Consent
(Required)
I understand
(Required)
Please note, we are out of network with all insurance companies. We can provide a superbill for you to get reimbursement from your insurance company. Payment is required at time of treatment.
Consent 2
(Required)
I agree
(Required)
I allow Anxiety Therapy LA to contact me via email or phone to connect about possible treatment. We will respond within 48 hours. Please make sure to check your spam folder if you have not heard from us.
