Name

Phone

Email Address

Date of Birth of the intended client (mm-dd-yyyy)

Location LocationSanta CruzWatsonvilleMontereyMonterey or WatsonvilleWatsonville or Santa CruzSan FranciscoAny

Combined Household Income (of whoever is paying for the therapy) Combined Household Income (of whoever is paying for the therapy)$0 ~ 2,000 per month$2,000 ~ 3,000 per month$3,000 ~ 4,000 per month$4,000 ~ 5,000 per month$5,000 ~ 6,000 per month$6,000 ~ 7,000 per month$7,000 ~ 8,000 per month$8,000~9000 per month$9000-10,000$10,000- 11,000$11,000-12,000other

# of People in Your Household # of People in Your Household123456 or more

Health Insurance Coverage Health Insurance CoverageNo InsuranceMedi-CalMedicare (not covered)Private Insurance (not covered)Double Coverage: Private Insurance plus Medi-Cal (not covered)Double Coverage: Medicare plus Medi-Cal (not covered)Victim Compensation BoardHealth Savings AccountOther

What Other Insurance?

What Medi-Cal Health Plan do you have? What Medi-Cal Health Plan do you have?Medi-Cal through CCAH (Central California Alliance for Health)Medi-Cal through San Francisco HealthplanMedi-Cal through the Partnership Health Plan of California (Many Northern California counties)Medi-Cal through LA Care Health Plan (Los Angeles county)Medi-Cal through Gold Coast Health Plan (Ventura county)Medi-Cal through a region not listed above (not covered)Medi-Cal through Kaiser Permanente (not covered)Medi-Cal through Anthem (not covered)Medicare (not covered)Other

What Medi-Cal Health Plan?

In what county are you a Medi-Cal subscriber? In what county are you a Medi-Cal subscriber?Santa CruzMontereySan BenitoMercedMariposa

In what county are you a Medi-Cal subscriber? In what county are you a Medi-Cal subscriber?AlpineButteColusaDel NorteGlennHumboltLakeLassenMarinMendocinoModocNapaNevadaPlacerPlumasSierraSolanoSonomaShastaSiskyouTrinityYubaYolo

Do you have both Medicare and Medi-Cal coverage? Do you have both Medicare and Medi-Cal coverage? Only Medicare Medicare and Medi-Cal Only Medi-Cal

Subscriber # (for CCAH this should be 8 numerals ending with one letter; for SF Healthplan it should be 11 numerals and no letters)

If Medi-Cal providers are not available (choose one of the following): If Medi-Cal providers are not available (choose one of the following):If there are no Medi-Cal providers available please connect me with a therapist who can see me for an "out of pocket" fee.If there are no Medi-Cal providers available, please inform me without connecting me to a therapist.I do not have Medi-Cal so I am seeking a therapist who can see me for an "out of pocket" fee.

What Private Health Plan do you have?

Type of Service Type of ServiceFamily TherapyCouplesInd. AdultInd. TeenInd. ChildGroup TherapyCrisis/ Emergency ServicesOther Services

Have you been seen at Shine a Light previously? Have you been seen at Shine a Light previously? Yes No

Please describe your previous experience at Shine a Light. Which counselor(s) did you see? When did you see them?

Issue you want help with Issue you want help withAlcohol & Drug UseAngerAnxiety, Panic, PhobiasAttention DeficitBehavior ProblemsCareer/Employment IssueChronic IllnessCo-dependency/ACACommunication SkillsDepressionDivorce/SeparationEating DisorderGrief/LossRelationship ProblemOther (describe below)Co-parent Counseling/MediationDomestic ViolenceEMDRInfidelityLGBTQ Identity/RelationshipsMen's IssuesWomen's IssuesMindfulnessStress ReductionParenting/Step ParentingFamily MediationAlternative RelationshipsSex CounselingSpiritual CounselingTrauma Recovery/PTSDPlay TherapyArt TherapyOther

Weekday Availability (Check all possibilities) Weekday Availability (Check all possibilities) Monday mornings Monday early afternoons Monday late afternoons Tuesday mornings Tuesday early afternoons Tuesday late afternoons Wednesday mornings Wednesday early afternoons Wednesday late afternoons Thursday mornings Thursday early afternoons Thursday late afternoons Friday mornings Friday early afternoons Friday late afternoons No Weekdays

Weekend & Evening Availability (Check all that apply) Weekend & Evening Availability (Check all that apply) Saturdays Sundays Monday evenings Tuesday evenings Wednesday evenings Thursday evenings Friday evenings No Weekends or Evenings

Message (Please include details about particular needs you have)

Counselor Preferences (if any) ie. gender, age, etc.

Virtual or In-person Preference Virtual or In-person Preference Tele/video sessions preferred In-person sessions preferred Open to either Tele/video sessions or in-person sessions

By which means can we contact you? (Check all that apply) By which means can we contact you? (Check all that apply) Email Text Voicemail