Cecilia Hanono | SimplePractice

Cecilia Hanono Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Are you located in California?

YES NO

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties - ADHD Depression Grief Relationship issues Trauma Substance use Reproductive health Perinatal care Behavioral issues Other

Administrative

Referral source

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Billing & Payment

Payment method

How do you plan to pay?

Insurance card upload

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Client Preferences

Preferred appointment times.

Please note that I see clients WEEKDAYS only.

Morning (9-11AM) Mid Day (12pm- 2pm)

Is there anything that you would like me to know in advance?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

My practice is purely telehealth at this time, are you ok with that?

Telehealth is provided by a HIPAA compliant app, and it is a video call. You get your confidential link 10 mins before the session?

YES NO

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.