Waitlist Form | Yolo Therapy

First name

Last name

Email

State of Residency

Phone

Birthday

Month

Day

Year

Insurance Information

If you intend to use insurance, please enter the name of your insurance plan. Do not include your member ID information. If you prefer to pay out of pocket, please enter "self-pay" in the field.

Clinical Concerns

Please provide a brief overview of the concerns you wish to address through therapy.

Availability

Please let us know which day(s) work best for you.

Multi choice

Morning

Afternoon

Evening

Please let us know what time(s) of day works best for you.

Thank you for taking the time to complete this form. We will connect with you as soon as availability permits.

Yolo Therapy

Therapy for Black People

Join Our Waitlist!

Enter your information in the fields below and we'll add you to the waitlist. Once a spot becomes available, we'll contact you to set up an intake appointment.