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Appointment Request

To schedule an individual, couples, or marriage therapy appointment or to obtain additional information about any of these counseling services, please fill out the form below or give me a call at 805-242-2696. If you are going to use insurance, please forward me a copy of your insurance card (front & back) and a valid ID, preferably drivers license, so that I can verify benefits before your initial appointment. 

Please open and read below to review my scheduling and cancellation policy. 

/userfiles/6164606/file/Toms Scheduling and cancellation policies.pdf

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.

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Helpful Forms

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