Appointment Request Form

To request a new appointment, please fill out the form completely and a member of our administrative team will contact you regarding the intake process.

 

Name *

First Name  Last Name

Email Address *

Which Clinic and Service Level? *

Please select the service you are interested in:

                                        Choose from below:                                        Menlo Park - Intensive Services (Moderate to Severe Symptoms)                                        Menlo Park - Outpatient Services (Mild to Moderate Symptoms)                                        Oakland - Intensive Services (Moderate to Severe Symptoms)                                        Oakland - Outpatient Services (Mild to Moderate Symptoms)                                        Oakland - Minecraft™ Social Skills Group                                        San Jose - Intensive Services (Moderate to Severe Symptoms)                                        San Jose - Outpatient Services (Mild to Moderate Symptoms)                                        San Jose - Minecraft™ Social Skills Group                                  

Phone *

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Legal Name on Insurance Card

Parent/Legal Guardian 1 Name

First Name

Last Name

Parent/Legal Guardian 2 Name

First Name

Last Name

Patient Date of Birth

MM

DD

YYYY

Why are you seeking services? *

Custody Status *

If you have sole legal custody, you will be required to submit documentation before receiving services. Please note that we do not do forensic evaluations.

                                        Married                                        Separated                                        Divorced - Joint Custody                                        Divorced - Sole Legal Custody                                        Widowed                                        Other                                  

Living Arrangement

Ever hospitalized?

Has your child (or yourself if over 18) ever been hospitalized for mental health issues? If yes, please provide the date(s)

Current Provider? *

Does your child (or yourself if over 18) currently have a psychiatrist, psychologist and/or therapist?

                                        Yes                                        No                                  Provider Names

If yes, please enter the names of the current providers:

Ever Any Violence *

i.e. physical assault, broken items, punched a hole in the wall

                                        No                                        Yes                                  Violence Description

Please describe the circumstances and most recent epsiode of violence

School *

School Problems *

Is your child having serious problems at school either academically or socially?

                                        Yes                                        No                                  Treatment Protocols

We do specific treatment protocols at our agency, and often require therapy to be done at our agency. If you have another therapist and/or psychiatrist , would you be willing to leave your current therapist and/or psychiatrist for 6 months to have a treatment course at BACA?*

                                        Yes                                        No                                  Substance Use *

Do you or your child currently use any illegal (marijuana, cocaine, ecstasy, etc) or legal (tobacco, alcohol, medical marijuana) substances of abuse?

                                        Yes                                        No                                  Substance Description

If yes, list substances and frequency of use:

Referred By and Date of Referral *

How did you hear about BACA?

Insurance                                        Aetna                                        Anthem (Blue Cross)                                        Blue Shield                                        Cigna                                        Cigna Behavioral                                        Humana                                        Kaiser                                        Medi-Cal                                        United HealthCare (Optum)                                        Valley Health Plan                                        Value Options                                        Other                                        Sliding-Scale Desired                                  

Insurance ID

Please enter your insurance ID number

BACA Policies Understood *

After you send the information, go to the Available Appointments page to look for appointments Enter your initials here to verify that you have read our office policies and understand that we take a $100.00 non-refundable deposit which is forfeited if the appointment is canceled or you do not show up for the appointment.

Insurance Subscriber *

Who is primary on the insurance plan?

First Name

Last Name

Insurance Subscriber DOB *

The date of birth of the primary insurance holder

MM

DD

YYYY

Insurance Phone Number (please reference back on card)

(###)

###

####

Medications (if any)

Are you willing to come anytime to be seen (this may increase your chances of getting a faster appointment)?

Preferred Language

Any cultural sensitivity we need to be aware of? If yes, please explain.

I would like to subscribe to the BACA newsletter 

 Yes

 

Your Name *
Your Name
Please select the service you are interested in:
Phone *
Phone
Address *
Address
Date of Date
Date of Date
If you have sole legal custody, you will be required to submit documentation before receiving services. Please note that we do not do forensic evaluations.
Has your child (or yourself if over 18) ever been hospitalized for mental health issues? If yes, please provide the date(s)
Does your child (or yourself if over 18) currently have a psychiatrist, psychologist and/or therapist?
If yes, please enter the names of the current providers:
i.e. physical assault, broken items, punched a hole in the wall
Please describe the circumstances and most recent episode of violence
Is your child having serious problems at school either academically or socially?
We do specific treatment protocols at our agency, and often require therapy to be done at our agency. If you have another therapist and/or psychiatrist , would you be willing to leave your current therapist and/or psychiatrist for 6 months to have a treatment course at BACA?*
Do you or your child currently use any illegal (marijuana, cocaine, ecstasy, etc) or legal (tobacco, alcohol, medical marijuana) substances of abuse?
If yes, list substances and frequency of use:
How did you hear about SafeSpace?
After you send the information, go to the Available Appointments page to look for appointments. Enter your initials here to verify that you have read our office policies and understand that we take a $100.00 non-refundable deposit which is forfeited if the appointment is canceled or you do not show up for the appointment.