Contact Donovan Individual and Family Counseling Services

First name

Last name

Email

Phone

Date of Birth

Month

Day

Year

Is this for:

Individual Therapy

Couples Therapy

Family Therapy

Is the person seeking services a minor (under 18)

Yes

No

If yes, Minor's Full Name and Date of Birth:

If the client is a minor, are there any custody orders, court orders, or other legal documents affecting consent for mental health treatment?* (Note: We require copies of these documents prior to the first appointment.)

Yes

No

Not sure

How Would You Like to Receive Services?* Please select your preferred service location:

In-person therapy Apple Valley, CA

Telehealth therapy (California)

Telehealth Texas (Cash pay or Lyra)

If requesting telehealth, what state will you physically be located in when receiving therapy?*

What Brings You to Counseling? Please briefly describe what you would like help with. You do not need to provide a detailed history at this stage.

Insurance (We currently only accept the insurances on this list).

IEHP

IEHP Covered California

Lyra

Out-of-Pocket (Private Pay)

I will pay out of pocket — Individual Therapy with a licensed therapist ($200 per 53-minute psychotherapy session)

I will pay out of pocket — Couples or Family Therapy with a licensed therapist ($225 per 50-minute psychotherapy session)

I will pay out of pocket — Individual Therapy with an Associate Therapist ($150 per 53-minute psychotherapy session) Telehealth only

I will pay out of pocket — Couples or Family Therapy with an Associate Therapist ($175 per 50-minute psychotherapy session) Telehealth only

If using IEHP: Please provide your IEHP Member ID.

If using Lyra: Please provide the name of your employer/company.

Insurance eligibility and authorization must be verified before services are provided. Completing this form does not guarantee that your insurance will cover services or that your requested service/location will be available.

Availability - What days and times are you generally available for therapy?* Please list your preferred days and time windows (e.g., Mondays 10am-2pm, Tuesdays after 5pm) and any scheduling limitations.

How did you hear about us?

Communication Preferences

Text Message Consent

I agree to receive text messages from Donovan Individual and Family Counseling Services, Inc.

I agree to receive text messages from Donovan Individual and Family Counseling Services, Inc. understand that message frequency varies and data rates may apply. I understand that I may opt-out by replying "STOP" at any time. I understand that I may reply "HELP" for assistance. I understand consent is not required to purchase goods or services.”

Privacy Policy & Terms

I acknowledge that I have reviewed and agree to the Privacy Policy and Terms and Conditions.*

By submitting this form, I acknowledge that I have reviewed and agree to the Privacy Policy and Terms and Conditions.

Privacy Policy:

https://www.scottdonovanmarriagefamilytherapy.com/copy-of-notice-of-privacy-practices

Terms and Conditions:

https://www.scottdonovanmarriagefamilytherapy.com/copy-of-privacy-policy-1

Important Notice

This form is for contacting the practice and requesting information about services. Submitting this form does not establish a therapist-client relationship and does not guarantee an appointment.

Please do not use this form for emergencies or urgent mental health concerns. If you are experiencing an emergency or believe you may be in immediate danger, call 911 or go to the nearest emergency department. For immediate crisis support, call or text 988.

Donovan Individual and Family Counseling Services, Inc.
Trauma Therapy

(EMDR Trained)

Important Notice

New Client Contact & Therapy Request

Donovan Individual and Family Counseling Services, Inc. Trauma Therapy

(EMDR Trained)

Important Notice

New Client Contact & Therapy Request

Donovan Individual and Family Counseling Services, Inc.
Trauma Therapy