Intake Form -Office & Telehealth

The Intake Form is used for office and Telehealth services. You print it, write your answers and bring it to your first appointment. For Telehealth, scan it and you will use the secure portal to send it to me. Intake is important, because you’ll let me know how to message you, your trusted contact person, and personal information to help me know things that matter for therapy.

Victor Bloomberg, EdD, LCSW

Psychotherapist in San Diego since 1991. Doctorate in Higher Education and Social Change (2021).

https://vblcsw.com
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Informed Consent