If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete the form to authorize a release of psychotherapy information:
If you want to use your insurance benefits and/or are unsure of your mental health benefits, we accept numerous types of insurance as well as out-of-network coverage. Please contact us at 714-654-1570 or fill out this form online to have your benefits verified. Please feel free to text message with your name, date of birth, address, insurance plan, policy #, ID number, authorization number and EAP info if applicable. Please let us know your time preferences as well.
***FORMS REQUIRE ADOBE ACROBAT IN ORDER TO VIEW OR FILL OUT ON YOUR LOCAL COMPUTER AS WELL AS TO PRINT.***
If you’re a new client:
Please complete the following mandatory forms and bring them to your first therapy session, or submit them below.
- Intake Form (Adult)
- Intake Form (Child)
- Intake Form (Adolescent)
- Self Survey (Fill out)
- Financial Agreement Form (Fill out and sign page 3 only)
- Privacy Notice & Informed Consent Contract
Please read and sign the following release of information and telemedicine forms:
Fill out and sign the last page of these forms.
- Authorization for Disclosure of PHI (Patient Health Information)
- Telemedicine Informed Consent Contract
Spanish
- Acuerdo con el Cliente y el Consentimiento Para la Terapia
- Autorización Para Liberar y Obtener Información Confidencial
- Aviso De Prácticas De Privacidad
- Información Confidencial de Admisión de Cliente