This information allows us to set up a Client Therapy Portal through which all intake documentation will be completed.

All information is confidential and protects the privacy and security of Protected Health Information (PHI) as required by the Health Insurance Portability and Accountability Act (HIPAA).

Type of therapy requested *

Individual (Adult)

Individual (under 18)

Couples

Family

Parent or Guardian if client is younger than the age of 18

Client's First Name *

Client's Last Name *

Is the client a resident of California?

Yes, the client lives in California.
No, the client lives outside of California.
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Client's Date of birth *

MM/DD/YYYY

Best Contact Phone *

Best Contact Email

Briefly describe the reason for therapy *

Single word answers like "depression" are adequate, if the word is enough to describe the need.

Payment Options *

In-network Insurance (please select from the list below)

Private Pay

Please note, "Private Pay" includes Out-of-Network insurance

Please provide the name of your insurance provider for administrative purposes

For Private Pay Clients

Insurance Provider

Kaiser
CalOptima
Aetna (Excluding SoCal Aetna HMO)
Cigna
Out of Network
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Not needed for Private Pay

Insurance Member Number/Medical Health Record Number

Not needed for Private Pay

Does the client have more than one insurance provider?

No (most common)
Yes
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Primary Insurance Provider

Secondary Insurance Provider

What therapist will the client be working with? *

Melissa Mellon, LMFT
Lorraine Burga, LMFT
Guadelupe Vera, LMFT
Sara Chee, AMFT
Ria Diddee, AMFT
Allison Huynh, AFMT
Simone Page, AMFT
Yasmeen Pardo, AMFT
Amanda Rogers, AMFT
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Most therapists are fully booked. If you are new to Moxie, please select "I don't know yet".

For Families and Couples, please list the name and age of anyone attending sessions.

Person 2
Person 3
Person 4
Person 5

How did you hear about Moxie?

Moxie Website

Friend/family

Former client

Insurance directory/referral

Another practice/therapist

Open Path

Solace Care

Social Media

ZocDoc

Select all that apply