Contact Us

Fields marked with an * are required

Your Name *

Client Name (if different)

Your Email *

Phone *

Reason for seeking therapy

Are you a Medi-Cal patient using Beacon's Partnership program? (PLEASE NOTE: We do not accept Kaiser, Value Options, or Medicare) *YESNO

Preferred therapist No preferenceCasandra McGee, MFTKimmy Peterson, MFTDebi Emmons, MFT

How did you hear about us? * Google searchAnother client/Parent of a clientRadio AdOther therapist referralDoctor referralPetaluma Health CenterFacebookDirect mail / postcardOther

At this time we only accept clients paying out of pocket or through Medi-Cal. If you are a Medi-Cal client, please let us know on this form.We only accept Medi-Cal through the Partnership Program of California, administered by Beacon Health Strategies, but NOT through Beacon’s Kaiser or Value Options programs. We do not accept any other types of insurance or EAP’s directly, but if you are paying out of pocket we can provide a statement for you to submit for insurance reimbursement.

*

(Submitting this form will generate an email sent to Petaluma Family Therapy staff. By submitting this form, you acknowledge that email is not a secure form of communication, and while unlikely, any emails may be intercepted and read by third parties.)