Welcome, we’re truly glad you’re here.

This form is designed to help us understand your story and connect you with a therapist who can best walk alongside you. We encourage you to answer the questions with openness and honesty. Your responses will remain confidential, except in situations required by state or federal law.

Once you submit the form, a therapist who is the right fit for your needs will reach out, typically within two business days, to schedule your first session. In some cases, our team may contact you beforehand to ensure we make the best match possible.

If you have questions, concerns, or specific requests, please don’t hesitate to reach out to us at cpcc@cpccounseling.com or (925) 820-1467.

Thank you for taking this step. We look forward to walking with you toward healing and growth.

Please be aware: We are not a crisis center. If you are in immediate danger please call 911. Other crisis resources are 988 and (800) 273-8255.

What is your full name?

First Name

Last Name

Please provide the full name of each participant

Those who will participate in our meetings. If just you, type "Self".

Please provide the date of birth for each participant

In the order of the participants listed above.

What is the best phone number to reach you?

If you're contacting us for a minor, please include cell phone numbers for all legal guardians. For couples or family counseling, please provide a cell phone number for each adult participant.

For a minor, is there a custody agreement (including separation)

Yes

Does Not Apply

What is your (or the participant’s) physical address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who currently lives in the participant’s household?

Please list the name, age, and relationship to the participant of each household member.

What are your (or the participant's) reasons for seeking therapy at this time? Text Area

Please share in 2-3 sentences.

What are the best times of day for you (or for the participant) to meet with a therapist?

Please list the days of the week and time ranges that work best.

If you have been referred to or would like to request a specific therapist, please provide their name below.

While we cannot guarantee their availability, if they do have openings, they will be the one to contact you.

Are you (or the participant) currently taking any psychiatric medications?

Please list names and dosages, if known.

Do you have any concerns about eating or nutrition for yourself (or the participant)?

Are you (or the participant) experiencing self-harm or suicidal thoughts?

Our standard fee ranges from $105 to $200 per 50-minute session, depending on the therapist’s licensing and certification.

If you prefer to be placed with a lower fee therapist, please let us know and we will do our best to accommodate your request.

Please note that we are out of network with all insurance providers.

If you plan to use your insurance benefits, we recommend contacting your insurance company directly to understand your out-of-network coverage options. Please also confirm with CPCC, prior to your first session, that we are capable of providing the required information to help you make the most of your benefits.

I have read and agree to the above

Do you prefer in-person or video sessions? *

Only in-person meetings

Only via video

Hybrid (a mix of both)

No preference

How did you hear about us?

Do you have a church affiliation?

If so, please share. If not, feel free to leave this blank.

Is there anything else you'd like us to know?

Consent to Contact and Share Information

By submitting this form, I give permission for Community Presbyterian Counseling Center (CPCC) to contact me using the phone number and/or email provided. I understand that this information will be used solely for the purpose of scheduling services and coordinating care.

I have read and agree to the above.