Parisa Emam, MS, LMFT, PLLC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

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Billing & Payment

Payment method

How do you plan to pay?

Insurance details

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Reason for care

What type of therapy are you seeking?

Please note that I practice via telehealth and am taking on only children and teens at this time.

What would you like me to know about why you're seeking therapy?

Anything you'd like me to know about the reason for therapy, past therapy experience, frequency or type of therapy you're seeking.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.