Appointment Request | The Heart Therapy Ce

Request an Appointment

Payment Method

Medical ID Number

Do you have any other insurance?

Yes

If so, is Medi-cal your primarty or secondary coverage?

Primary

Secondary

First Name

Last name

Guardian Name (if client is under 18)

Client's Birthday

Month

Day

Year

Phone

Okay to leave a detailed message?

Yes

Clinician request or referral?

Have you attended therapy sessions before? If so, how long has it been since your last session and what was your experience like?

What are you looking for in a therapist and in the therapy experience?

What is your availability (days & times preferred)?

Are you able to attend sessions at our Ocean View Ave location in Santa Cruz? Please indicate if you are looking for telehealth only.

Anything else you would like us to know when trying to find the best therapist for you?

Note:

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

Please submit this form if you would like to make an appointment
We offer services based on a sliding scale of $130 - 250/hour depending on household income.
We are credentialed with:
- Medi-Cal/Alliance
- CCAH
- AETNA
We also accept out-of-pocket payment (we can provide a Superbill and an electronic submission option)