Waitlist Form Name * First Name Last Name Contact Person (If Different) First Name Last Name Phone * (###) ### #### Email * Schedule Availability/Notes Service Type * Telehealth Therapy In-Person Therapy (Arroyo Grande) Play Therapy (Ages 4-12) ADHD Assessment Autism Assessment Payment Type * Direct Cash Pay Health Savings Account (HSA) Workers Compensation CenCal Insurance Medicare (Not United or Humana Medicare) Aetna Insurance Out of Network Insurance (Cash Pay + Superbill) Requested Therapist * Open to Any Therapist Jaime Cruz, AMFT Kristina Berger, RPA Daniel Pasquini, RPA Liza Roth, AMFT Megan Krause, AMFT Peter Kremidas, APCC Rebecca Sosa, AMFT Thank you!
