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.
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
Patient Legal Name on Insurance Card
Parent/Legal Guardian 1 Name
Parent/Legal Guardian 2 Name
Patient Date of Birth
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
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 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
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?
Insurance Subscriber DOB *
The date of birth of the primary insurance holder
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)?
Any cultural sensitivity we need to be aware of? If yes, please explain.
I would like to subscribe to the BACA newsletter