Discovery Counseling Center

Discovery Counseling Center Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Disordered Eating Other

What kind of care is being sought?

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Additional information for reason for seeking care.

Please add any additional information that you feel would be important for our intake coordinator or your future clinician to know.

Limited to 600 characters

Has the client been seen in the Discovery Counseling Center Clinic or SCIP before?

Are you returning to care? If you or a minor in your care have previously received services at DCC, SCIP, ASP, or SARB, please reach out to our front desk at (925) 837-0505 or discoverycounseling@discoveryctr.net. This form cannot be processed for existing clients—our team will help reactivate your file.

Yes No

Preferred modality

Administrative

Referral source

Enter how you were referred to our services

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Billing & Payment

Our standard fee for service is $160 per session. We offer a sliding scale based on annual household income.

Check "Yes" if you would like to discuss financial assistance with intake coordinator.

Yes No

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.