SCCC - Contact Form

Are you an L.A. Care Medi-Cal plan subscriber or an L.A. Care Covered California plan subscriber?

Date of Birth:

I confirm that I am resident of California

Group of interest (optional) Only active groups currently accepting public requests are shown. Choosing one expresses interest and does not enroll you. Are you currently required by a court to attend therapy?

Clients age 12 and older may be eligible to request Group services without a guardian signature. SCCC must complete a professional self-consent review for ages 12–17 before the consent form is sent. Group eligibility is reviewed separately by staff.

Emergency Contact
Would you like to provide an emergency contact? You may provide a contact or sign an acknowledgment choosing not to provide one. I’ll provide an emergency contact I choose not to provide one
Full Name * Phone # * Relationship *
Acknowledgment of No Emergency Contact: I, the client named above (Client’s Name), acknowledge that I have chosen not to provide an emergency contact to Southern California Counseling Center (SCCC). I understand the implications of this decision and acknowledge the following: Emergency Situations: In the event of an emergency where I am unable to communicate or my counselor cannot reach me, the staff of SCCC will not have a designated person to contact on my behalf. My counselor will contact local emergency personnel to conduct a wellness check. Responsibility: I accept full responsibility for the decision not to provide an emergency contact and release SCCC and its staff from any liability arising from this decision. Changes to Decision: I understand that I can choose to provide emergency contact information at any time by notifying the staff of SCCC and completing the appropriate forms. Consent and Signature: By signing below, I confirm that I have read and understood the above information. I voluntarily choose not to provide emergency contact information and accept the associated risks and responsibilities. Sign the acknowledgment Type your full legal name

Emergency Contact

Would you like to provide an emergency contact?

You may provide a contact or sign an acknowledgment choosing not to provide one.

I’ll provide an emergency contact I choose not to provide one

Full Name *

Phone # *

Relationship *

Acknowledgment of No Emergency Contact:

I, the client named above (Client’s Name), acknowledge that I have chosen not to provide an emergency contact to Southern California Counseling Center (SCCC). I understand the implications of this decision and acknowledge the following:

Emergency Situations: In the event of an emergency where I am unable to communicate or my counselor cannot reach me, the staff of SCCC will not have a designated person to contact on my behalf. My counselor will contact local emergency personnel to conduct a wellness check.
Responsibility: I accept full responsibility for the decision not to provide an emergency contact and release SCCC and its staff from any liability arising from this decision.
Changes to Decision: I understand that I can choose to provide emergency contact information at any time by notifying the staff of SCCC and completing the appropriate forms.

Consent and Signature:

By signing below, I confirm that I have read and understood the above information. I voluntarily choose not to provide emergency contact information and accept the associated risks and responsibilities.

Sign the acknowledgment

Type your full legal name

Please write 2–4 sentences. Details can be discussed during screening. 0 / 600 characters