Your Intake Forms Will Include:

Informed Consent for Psychological and Support Services

This is a long form (we know, sorry!) that explains various important issues, such as the philosophy behind therapy services, your rights as a patient, our rights as providers, limits of confidentiality, and other helpful information.

Consent for Psychological Services for Minor Child

This form must be signed by all legal guardians of a client under the age of 18 before starting services. If the custodial parents/legal guardians are currently separated or divorced, both parties are required to sign a Consent for Psychological Services for Minor Child. If one of the custodial parents/legal guardians has full legal custody, a copy of the most recent custody decree would need to be faxed to 714-455-9568 before your child begins treatment.

Fees, Payments, Cancellations, and Insurance Policy

This form reviews the fees for services, payments, our 48-hour cancellation policy, our out-of-network provider status, and what you may need to get reimbursement from your insurance provider.

Credit Card Information

You will need to add a credit card to your secure client portal before your first appointment. We accept all major credit cards, HSA, or FSA. You will have access and control of your credit card through the client portal and can change your card at any time. Payments will be charged to this credit card within 24 hours of the rendered service. You may also sign into your secure client portal to make payments.

HIPAA Notice of Privacy Practices

This form goes over the limits of confidentiality and HIPAA.

Arbitration Agreement

This form reviews our arbitration policy in the event of a dispute.

Biopsychosocial History Form

This form collects basic information about you, your background, and why you’re seeking therapy now.

Baseline Mental Wellness Screening (Heads Up Checkup)

As a new client, you’ll receive a baseline mental wellness screen to inform your provider of how best to meet your needs. This initial screen also allows us to create specific treatment plans and track your progress.

World Health Organization Disability Assessment Schedule (WHODAS) (Optional)

This form asks about difficulties due to health/mental health conditions.

Release of Authorization or Information (Optional)

The law requires licensed mental health professionals to keep your information confidential under HIPAA standards. Completing this form is the only way providers can discuss your care with anyone (e.g., your partner, doctor, former therapist, etc.). Although this form is optional, we strongly encourage you to complete it with the name of the referring medical provider to ensure continuity of care. If you were not referred to our practice by a medical provider, please feel free to complete this form with the name of anyone else you may want to be involved in your care.