If you would like your therapist 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.***
Privacy Notice and Informed Consent
Financial Agreement
- Insurance & Private Pay (Complete last page only)
- Medi-Cal
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)
- Telehealth 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
- Contrato de Consentimiento Informado de Telemedicina