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Hi! What's your first name?
Thanks ! And your last name?
What's the best email to reach you?
We'll send confirmation and next steps here
What's your phone number?
We'll use this to contact you about your intake if needed
What's your date of birth?
🔒 We use this to securely verify your identity when you log in to our portal
What type of therapy are you looking for?
How many people will be in therapy?
Person 2 of 3
We need information for each person in therapy
Are you a California resident?
We can only serve California residents at this time
Would you like text updates from us?
Optional communication preference for intake updates and reminders
Would you like email updates from us?
Optional communication preference for confirmations, resources, and intake updates
What brings you to therapy today?
Share as much or as little as you're comfortable with
This helps us match you with the right counselor (optional)
Demographics
What's your address?
State: California (we serve CA residents only)
Demographics
Are you currently employed?
Demographics
How do you identify your gender?
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Demographics
What are your pronouns?
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Demographics
What is your ethnicity?
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Demographics
What is your relationship status?
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Demographics
What is your sexual orientation?
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Demographics
What language do you prefer for therapy?
Emergency Contact
Who should we contact in an emergency?
Financial Information
How many people live in your household?
Including yourself (used to determine your fee)
Financial Information
What is your monthly gross income?
Before taxes - used to determine your sliding scale fee
A Few More Questions
How did you hear about us?
A Few More Questions
Is this your first time seeking therapy?
A Few More Questions
Are you currently in counseling elsewhere?
Availability
When are you available for sessions?
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9-10am
10-11am
11am-12pm
12-1pm
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2-3pm
3-4pm
4-5pm
5-6pm
6-7pm
7-8pm
8-9pm
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Intake Request Form

Please fill in the Intake Request Form to request an intake session with an SCCC counselor. All intakes are currently taking place via video conference.

If you think you may have a medical or mental health emergency, please call 911.

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