Psychotherapy Intake Form Email address* Name*Best phone number to reach you or client*Age of Client/Patient seeking services* MM slash DD slash YYYY Calling for: Self Spouse or Partner Child Friend Sibling Parent Parent Consultation and Education Name of client if not calling for selfClient age*Client location City of current residence AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country We currently are only providing therapy to clients who are physically living in California. You must be in the state of CA to render services* I understand that Kimberley and her staff can only provide services to CA residents onlyPrimary condition:* 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 Marriage counseling Life Stressors Orthorexia-ARFID Anorexia Nervosa Bulimia Nervosa Binge-Eating Primary condition (Other)Previous TherapyPrimarily interested in:*Please note at this time we are only providing online therapy until it is safe to meet in person. Individual therapy in person Individual therapy online Family therapy Couples therapy One-time Consultation Therapist preference:*We have 8 licensed therapists who provide treatment for our patients/clients. For more information about our therapists please see https://kimberleyquinlan-lmft.com/qualified-mental-health-therapists-calabasas-california/ Male Female First available Lowest fee This field is hidden when viewing the formOffice Location ** Click all that interest you. Teletherapy (via a secure online platform) Face-to-face sessions only (Calabasas office) Face-to-face sessions only (Ventura office) Office Location* Teletherapy (via a secure online platform) Face-to-face sessions only No Preference NotesPreferred day of the week (Check all that apply)* Select All Monday Tuesday Wednesday Thursday Friday Saturday Sunday Other Preferred time of day (Check all that apply)* Morning Afternoon Evening Flexible schedule Depends on the day After school hours only Other Preferred time of day (other)How did you hear about us? IOCDF website Psychology Today Therapy Den Google Other Online location My Therapist Another therapist My doctor My psychiatrist Social Media Your Anxiety Toolkit Podcast Other How did you hear about us?How did you hear about us?How did you hear about us?How did you hear about us?Medicare Provider Status: This practice is an Opted-Out provider. This means we are not contracted with Medicare. Medicare will not reimburse you for the cost of our services. If you are a Medicare beneficiary, we will need to enter into a private contract for therapy services in order for us to treat you.Are you a Medicare beneficiary?* Yes No Please note, we are out of network with all insurance companies.* I understand We can provide a superbill for you to get reimbursement from your insurance company. Payment is required at time of treatment.This field is hidden when viewing the formHow did you hear about us? (Dr, Therapist, Google Search, Social Media, Your Anxiety Toolkit Podcast)I allow Kimberley Quinlan (and her assistant) to contact me via email or phone to connect about possible treatment* I agree
