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Make an Appointment
If you know which therapist you'd like to see, use one of  these two links to go to a form that will only be seen by her.  Or, use the form on this page  if you'd like us to determine which therapist can best meet your needs.   (Reading about Who We Are and  our Hours.  may help you decide who's the best match.)

Appointment request form for Jeanne Courtney, MFT 

Appointment request form for Valerie Igl, MFT



APPOINTMENT REQUEST FORM

By answering these questions, you can help us get to know you, and get a head start on providing the best therapy for your needs. Please fill in as much or as little information as you feel comfortable with. The only required fields are your first name and phone number. After you submit the form, you will receive a call within two business days, to answer any questions you have and confirm an appointment. If you would like to reach us sooner, or prefer not to use the form, you can simply call 510-527-5662.

(Use cursor or TAB key to move to the next field; hitting ENTER will submit the form.)

First Name:
Last Name:
Age:
Phone(s):
Address:
City:
Zip Code:
Email:
Type email again:
Okay to leave a message?
How did you hear about us?
Please specify:
What brings you to therapy?
Type of therapy you want:
For family / couples therapy, enter names of everyone coming in and have each adult submit this form separately.
Frequency you want:
Please check all possible appt times:  

Mon afternoon, El Cerrito

Mon evening, El Cerrito

Tues afternoon, El Cerrito

Tues evening, El Cerrito

Wed afternoon, El Cerrito

Wed evening, El Cerrito

Wed afternoon, San Francisco

Wed evening, San Francisco

Thur morning, El Cerrito

Thur afternoon, El Cerrito

Thur evening, El Cerrito

Fri afternoon, El Cerrito

Fri evening, El Cerrito

Comments about scheduling:
How will you pay?
If Medi-Cal, do you also have Medi-Care?
If paying independently, do you need to request a low-income fee reduction?
If yes, indicate gross (before taxes) annual household income from all sources:
 
No. of adults in household:
No. of children:
Please list any psychiatric medications you take:
Have you ever . . . had drug or alcohol problems?
. . . thought about or attempted suicide?
. . . been stalked, threatened, or assaulted?
. . . experienced domestic violence?
. . . done anything violent?
Please describe:
How long since you had a therapist?
Comments about past therapy:
What is stressful in your life right now?
What is going well in your life right now?
Anything else you want us to know?
 

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