Get in touch.

Use this form to tell us more about what brings you to therapy. We’ll respond within 24 hours to match you with the therapist whose expertise and availability best aligns with your needs & goals.

925 Broadbeck Dr Suite 225Newbury Park, CA 91320info@conejovalleycounseling.com 805.242.3120

Name

First Name (required)

Last Name (required)

Email (required)

Phone (required)

Are you looking for telehealth or in-person therapy? (required)

How did you hear about our practice? (required)

Please provide the name of your insurance company: (required)

If you do not plan to use insurance, please write “None”.

What are the presenting issues? (required)

Note: Please do not provide any personal information in this form.

If the counseling is for a minor, please provide their age:

Are you interested in working with a particular clinician? (required)

If so, choose their name below. If not, select “None.”

We see clients the same day and time each week. Please provide some consistent days and times that work for you: (required)