Contact us.dr.claffey@thewellcounselingcenters.org(661) 917-3815 / (888) GIVE-HOPEStevenson Ranch, CA 91381 Name * First Name Last Name Email * Insurance Provider & Plan (if applicable) If you are paying out of pocket, please note "Self-Pay" Have you had any previous hospitalizations for mental health reasons? If yes, please provide approximate dates and reason: Have you ever experienced or been diagnosed with psychosis (e.g., hallucinations, delusions, or disorganized thinking)? Is there anything else you'd like us to know before your first appointment? * Confidentiality: All information you provide in this form is kept private and secure. Your responses are only viewed by our clinical staff and used for intake and assessment purposes. This is not a crisis service: If you are in crisis or need immediate support, please call 911 or contact the Suicide & Crisis Lifeline at 988. We are not able to provide emergency or same-day services. I Understand Thank you!
