Get in touch.

Use this form to share a bit about yourself and what your needs are - I will respond to schedule a complimentary 15-minute consultation. During our consultation, I’ll be able to answer your questions. If it appears that we are a good fit to work together, we will go ahead and schedule your first appointment.

Name

First Name

Last Name

Phone

(###)

###

####

I am interested in Individual or Couples Therapy

In-person or Video (Telehealth) Sessions?

You availability Tuesdays and Thursdays?

How did you hear about me?

Is there anything you'd like to share with me such as symptoms?

Note: Please do not include Personal Health Information in this form.

By checking this box, I acknowledge that electronic communication, including web forms and email, is limited in terms of privacy and may be intercepted by a third party. I hereby release Cristina Cano LMFT from any and all liability that may occur due to electronic communication over a non-secure network. I acknowledge and understand that a therapeutic relationship starts after my first intake session with therapist.

I AGREE

Haven Christian Counseling

Serving all California residents including Los Angeles, San Diego, and the Bay Area.

9431 Haven Ave Suite-229 - Rancho Cucamonga CA 91730. E:CristinaCanolmft@gmail.com P: 562.204.6202

If you or someone you know needs immediate help, call 9-1-1 or go to the nearest emergency room. For non-emergency resources & support, click here.