Our Team Services Contact Forms Resources

Get in touch

For more information or if you would like to make an appointment, please contact Vicki or submit the Initial Contact Form below.

Vicki

Phone

(251)316-0060

Fax

(251)316-0062

Email

Vicki@bayareaclinical.com

Initial Contact Form

Name of client

Name of person completing this form, if different from client

Relationship to client

Date of Birth

Cell Phone

Home Phone

AddressEmail AddressGender

Preferred method of contact:Cell PhoneEmailHome Phone

Have you ever been a client here before?YesNo

Preferred method of payment:InsuranceSelf-PayOtherIf Other, please explain.

Insurance CompanyPolicy NumberGroup NumberInsurance Phone Number (listed on back of card)

Subscriber Name

Subscriber relationship to clientSubscriber date of birthIs there a particular clinician you'd like to work with?Catalina M. Arata PhD, LLCM. Hope Jackson PhD, LLCSusie Boucher MS, LPC, LLCSage Moye LPC, LLC

Preferred appointment times (check all that apply):

MondayMorningLunchtimeAfternoon/Evening

TuesdayMorningLunchtimeAfternoon/Evening

WednesdayMorningLunchtimeAfternoon/Evening

ThursdayMorningLunchtimeAfternoon/Evening

Why are you seeking treatment?

Please note that it may take up to four business days for a response to your inquiry. Submission of an inquiry does not guarantee an appointment with one of our providers. In the event of an emergency call 988 or 911 or go to your nearest emergency room.

Thank you! Your submission has been received!

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