First Name *

Chosen Name

Last Name *

Are you filling this form out on behalf of someone else? If so, please provide your name and describe your relationship in the "other" section.

Pronouns

Phone *

Email *

Date Of Birth *

Age *

Insurance Type *

Do you live and reside in Contra Costa County? *

Contact Preference?

In a few sentences, describe why you are seeking therapy today. *

If this is a life-threatening emergency, please call 911 or go to the nearest emergency room.

If you are in crisis, please call the

Contra Costa Crisis Center at 988
A3 Crisis Response 24/7 at 844-844-5544
Text HOPE to 20121
Trans Lifeline (by and for trans/nonbinary people) at 1-877-565-8860
LGBTQI+ Trevor Lifeline at 1-866-488-7386 or text START to 678-678.

Are you currently experiencing thoughts of suicide? *

If yes, please describe.

Is your living situation currently safe right now? *

Have you ever been hospitalized or sought care for a mental health crisis in the past year? *

How did you find out about Rainbow Community Center?

By checking this box, I consent to receive non-marketing text messages and emails from Rainbow Community Center of Contra Costa County related to clinical and support services (e.g., appointment scheduling, reminders, follow-ups, and service coordination). Message frequency varies. Message and data rates may apply. Text HELP for assistance or STOP to opt out at any time. See our Privacy Policy and Terms of Service.