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Fill Out Form

Answer a few questions and we'll match you with the right counselor within 24-48 hours.

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 schedule your first session
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
Can we text you?
We may send appointment reminders and updates via text
May we email you?
We'll send confirmations, resources, and important 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?
Select all that apply
Demographics
What are your pronouns?
Select all that apply
Demographics
What is your ethnicity?
Select all that apply
Demographics
What is your relationship status?
Select all that apply
Demographics
What is your sexual orientation?
Select all that apply
Demographics
What language do you prefer for therapy?
Emergency Contact
Who should we contact in an emergency?
Billing Information
How many people live in your household?
Including yourself (used to determine your fee)
Billing 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?
Scheduling
When are you available for sessions?
Click on the time slots when you're available
Mon Tue Wed Thu Fri Sat Sun
8-9am
9-10am
10-11am
11am-12pm
12-1pm
1-2pm
2-3pm
3-4pm
4-5pm
5-6pm
6-7pm
7-8pm
8-9pm
Payment Setup
Add a payment method for future sessions
Your intake meeting is FREE - your card will NOT be charged today.
We securely save your card for convenient payment after future appointments.
Secured by Stripe - We never store your full card details
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Intake Complete!

Thank you for completing your intake form.

Your information has been securely submitted. Our team will review your intake and reach out to schedule your first session.

What's next?
We'll contact you within 24-48 hours to schedule your first appointment.

Questions? Email us at [email protected]

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You're all set!

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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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