La Cocina General Services Interest Form

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Your Name* This field is required.
Primer Nombre
Apellido
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Your telephone number* This field is required.
Area Code
Phone Number
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Your Email Address
example@example.com
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What is the best way for us to communicate with you?* This field is required.
Telephone call, and yes! It's okay to leave me a voice mail message
What's App messaging
Text
Email
All of the above
Other
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What language should we use when contacting you?* This field is required.
Spanish
English
Both Spanish & English work!
Other
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Please share more about your interest in our services.* This field is required.
I am an adult who needs therapy (includes couple or family therapy)
I am a youth or young adult, and I believe I need therapy (ages 15 to 18 years old only)
I am the parent or caregiver of a minor who needs therapy
I am the parent of a minor who the school or another therapist says needs to be assessed
I am a caring professional or community liaison referring someone I work with, or who receives services through my place of employment.
I am a member of La Cocina's team
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Please confirm these services are for you, or for you and your family.* This field is required.Please keep in mind any services you seek must include you, and you must be at least 12-years old to receive individual services at La Cocina. Due to privacy laws, La Cocina is unable to contact youths (ages 12-18 years old) or adult persons you may know but who have not completed this form this form for themselves. If you know a youth or adult who needs individual therapy, please share this link with them so they may complete the form for themselves.
Yes! I confirm that these services are for me, or for me and my family
No. These services are not for me.
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You indicated that you are an individual youth (12 years or older) or adult who seeks services at La Cocina. What type of services do you seek at this time?* This field is required.
I am looking for therapy for myself
I am looking for therapy for me and my family
I am looking for therapy for me and my partner or spouse
I am looking for group therapy with others going through what I am going through
I don't know what type of therapy/services I need, but I know I need help
Other
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What is your date of birth?* This field is required.
Date
Month
Day
Year
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Do you have health insurance, including Medicaid?* This field is required.
I have Medicaid
I do not have health insurance
I have a private health insurance
Other
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You indicated that you do not have health insurance. Please tell us more about your financial situation so we may understand how best to support your needs.* This field is required.
I really need these services, but I cannot pay for them at this time.
I really need these services, and I can pay something to help La Cocina cover its costs.
I really need these services, and I can pay for them in full.
Other
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Please tell us a bit more about what leads you to seek services at this time. Please be specific and share how you believe we can help you and/or your family.* This field is required.
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You indicated that you are the parent of a minor child who needs support. What type of support services do you think your child needs at this time?* This field is required.If you or your family need immediate help, call 9-8-8. Remember that La Cocina does not respond to emergencies, and that it will take us 48-hours to get back to you!
My child has been through a lot and needs therapy
My child needs to be assessed by a professional because it's clear something is wrong and our family does not know how to help
My young child's development seems to be behind that of other children, so I would like to have them assessed by a professional
A teacher or another professional told me that my child needs help, but I am not sure what type of services they need.
I need help parenting my child. I have tried different ways of parenting, but my child seems to need a different approach.
I don't know what type of services my child needs, but I know they need help.
Other
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How old is your child? (Numbers only, please).* This field is required.
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Does your child have health insurance?* This field is required.
Yes, my child has Medicaid or CHIP
Yes, my child has private health insurance (through an employer or personal pay)
No, my child does not have health insurance
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Please share a bit more about what leads you to seek support services for your child. We would like to know how you believe La Cocina can help? And what you already know about your child's current challenges?* This field is required.
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Does this person/family know you are referring them for services at La Cocina?* This field is required.Please note that La Cocina will not contact anyone who does not know they are being referred for services.
Yes, they know they are being referred for services.
Not, they don't know they are being referred for services. I will inform the person/family about my decision to refer them for services before re-submitting this form.
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Please upload a copy of the completed and signed release of information (ROI) authorizing you to make a referral on behalf of this individual/family.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Name of your organization or community group:* This field is required.
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What type of services does this person/family need at this time?* This field is required.Please keep in mind that referrals for Latine persons usually result in better outcomes when the individual and/or family in need refers themselves. Whenever possible, we encourage you to help the individual/family who needs the services complete this form for themselves.
Individual therapy for an adult, young adult (18-22 years old) or youth (15-18 years old)
Family therapy, including couple's therapy
Prenatal or perinatal support for a pregnant person/family. This may include support for a parent with an infant or child younger than 12-months old.
Individual therapy for a minor child (younger than 15-years old)
Neurodevelopmental, psychological, or behavioral assessment for a minor child (younger than 15-years old). This includes all forms of assessment.
Court ordered psychological, behavioral or forensic assessment for a minor child or youth, including for immigration purposes.
Court ordered psychological, behavioral or forensic assessment for an adult, including for immigration purposes.
I don't know what type of services are needed at this time
Other
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You indicated that you are a caring professional and/or member of our community who would like to refer someone you know for services. In your view, what type of services does this person/family need at this time?* This field is required.Please keep in mind that referrals for Latine persons usually result in better outcomes when the individual and/or family in need refers themselves. Whenever possible, we encourage you to help the individual/family who needs the services complete this form for themselves.
Individual therapy for an adult, young adult (18-22 years old) or youth (15-18 years old)
Family therapy, including couple's therapy
Prenatal or perinatal support for a pregnant person/family. This may include support for a parent with an infant or child younger than 12-months old.
Individual therapy for a minor child (younger than 15-years old)
Neurodevelopmental, psychological, or behavioral assessment for a minor child (younger than 15-years old). This includes all forms of assessment.
Court ordered psychological, behavioral or forensic assessment for a minor child or youth, including for immigration purposes.
Court ordered psychological, behavioral or forensic assessment for an adult, including for immigration purposes.
I don't know what type of services are needed at this time
Other
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How old is the primary adult, youth or child who needs these services?(Numbers only, please)* This field is required.If you do not know the child or youth's exact age, please enter an estimate of their age.
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What is the individual/family's primary language?* This field is required.
Spanish
English
Both Spanish and English are okay
Other
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Name of the individual we should contact re: this referral:* This field is required.
First Name
Last Name
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Telephone number of the individual we should contact:* This field is required.
Area Code
Phone Number
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Tell us a bit more about the child, adult and/or family needing support at this time. What leads you to make this referral? And how do you think La Cocina can help? Please be specific so we may determine how best to contact this person/family.* This field is required.
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Does this family have an open case with their county's child welfare system/ Department of Human Services or another penal system?* This field is required.
Yes
No
I don't know
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How did you learn about La Cocina's services? Please select all that apply.* This field is required.
A friend or family member
My church
Another agency, family liaison or community navigator
Someone from La Cocina contacted me with information
I am a regular collaborator of La Cocina
La Cocina's Website
La Cocina's Social Media Outlets
Other Agencies' Social Media Outlets
El Tigre Spanish Radio Station
Other
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Would you like to receive La Cocina's monthly newsletter?La Cocina's newsletter is our primary form of communication with our stakeholders, and includes valuable updates and insights which may be of interest to you.
Yes! Please add me to your online mailing list
No, thank you.
I already receive your newsletter
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Is there anything else you would like to share with us at this time? If so, please write it in the space below.
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