Book An Appointment - Freedom Within Center | Counseling

Preferred First Name

Preferred Last Name

Phone Number

Date of Birth

Are You Currently Active Duty Military?

Yes No

Check any of the below that you identify as:

Military Veteran Family Member of an Active Duty Service Member

Is the Potential Client at least 18 years of age?

Yes No

Please note that we only see clients who are at least 18 years of age. If the client is a minor we are happy to send you a referral list of practices who serve minors if you complete this form.

Please specify if referral source selected was "other"

Select your preferred payment/insurance

Please specify if your chosen payment was "other"

If you are wanting to use insurance to pay for services, we have providers who are in network with Aetna, Cigna, Kaiser, Lyra, Tricare and VA/TriWest. If you have a different insurance you can inquire if your insurance offers "out of network benefits" and if so, we can provide you a "Superbill" to submit to them directly.

Insurance ID Number (For Tricare folks this is your DBN 11-digit number on the back of your card, not your DOD ID)

Do you have second form of insurance other than what is listed above? (i.e. do you have a secondary insurance?)

Yes No

Type of Therapy Preferred

In person Telehealth (video counseling) Open to either

To select multiple hold down ctrl or command when making your selections

What are you seeking therapy for?

Please specify if your therapy selection was "other"

Is there a particular clinician you would like to work with?

Legal Name (If different from preferred name, required for insurance purposes)

Preferred Pronouns

What days do you prefer for appointments? (Ctrl +click to select multiple days)

What are your preferred timeframes for your appointments? (Ctrl + click to select multiple times)

Is there anything else you would like to share? Or specific scheduling requests?

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. You also agree to have someone from our team contact you by phone and/or email. *

Appointment Request

As Of March 21st, We Have Relocated To: 2254 San Diego Ave. San Diego, CA 92110

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Group/Workshop Interest