Name *

First Name

Last Name

Phone *

(###)

###

####

Provider *

If you are interested in working with a specific provider, indicate your preference below (you may choose more than one provider)

Erin Skiffer, Psy.D. (Corte Madera & San Francisco)

Nicolas Chu, Psy.D. (Corte Madera)

Leslie Yan Meier, Ph.D. (San Francisco)

Stephanie Lopez, Psy.D. (Corte Madera & San Francisco)

Alexis Petrakis, Psy.D. (Petaluma & Corte Madera)

Brandi Marcaletti, Ph.D. (Corte Madera)

Alissa Vannet, Psy.D. (Corte Madera & Oakland)

No Preference

Location *

What is your preferred location?

Corte Madera

San Francisco

Petaluma

Oakland

Virtual Only

Have you been treated in any of the following settings (check all that apply)? *

Medication management with a psychiatrist

Previous psychotherapy

Intensive Outpatient Programs (IOP)

Partial Hospitalization Programs (PHP)

Psychiatric hospitalization

Residential Treatment

None of the above

Is the patient seeking treatment insured by Medicare?

Yes

No