Home Parent Questionnaire

Parent Questionnaire

If you are interested in seeking therapy for your child, please answer the following questions: Please select yes or no.

All fields denoted by an asterisk (*) are required.

1. Do you live in the greater Los Angeles area? *

2. Do you have health insurance which covers mental health counseling? *

Please confirm with your insurance company you do not have a deductible, or your deductible has been met. Otherwise my rates (as of March, 2014) are as follows:

  • $205 for initial meeting with each parent before meeting the child.
  • $175 for all 50 minute sessions with children.
  • Fees are paid in cash or check at the beginning of each session.
  • I am a provider for the following insurance plans: Anthem Blue Cross, Aetna PPO, United Behavioral Health, United Health Care and Magellan.
  • Please be advised that BOTH parents need to sign an informed consent form allowing their child to be in treatment with me.
  • 24 Hour Cancellation is required to avoid paying a late fee of $150. (ie: if your appointment is at 1 pm Tuesday, you must call by 1 pm Monday, the day before).

3. Have you and your ex-spouse discussed divorce with your child? *

It is most important parents tell their children together and function as a united front. It is important to reassure your child that he/she will live with both parents and that both of you will take care of them.

Your Name *

Your Email *

Daytime Phone *

Questions or Comments

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