California Patient Information and Consent

First Name

Last Name

Your email

Phone Number

How can we help you?

Therapy

Medication Management

Street Address

City

Zip Code

State

Date of Birth (MM/DD/YYYY)

Social Security #

Gender

Male

Female

Is the patient a child or minor?

Yes

No

Fathers Name

School Name

Mothers Name

School Phone #

The main problem that brings the patient to the clinic is

Please provide us with your pharmacy's phone number

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Do you have any other medical conditions?

Could you be pregnant (women in childbearing years)?

Yes

No

Have you ever had previous experience with psychiatry, counselling, or therapy?

Yes

No

Was the care you received helpful?

Yes

No

Was your treatment experience negative in any way?

Yes

No

Have you ever sought or received treatment for any mood issues?

Yes

No

Do you smoke, or have in the past?

Yes

No

Do you drink alcohol, or have in the past?

Yes

No

Do you currently, or have in the past, used any "street drugs"?

Yes

No

List all prescription and non-prescription medications you currently take

Please separate each medication to one per line.

What medications are you allergic or have had bad reactions?

What is your employment status?

Employed

Unemployed

Place of Employment

Work Phone Number

Do you have a coupon code?

How do you plan on paying for this session?

I will pay myself

I will pay through my insurance

Why are you paying out of pocket?

You have no health insurance.

You have health insurance but you do not want your insurance billed and instead want to pay out of pocket.

Other

Please specify the reason why you are paying out of pocket

Do you have Medicare?

Yes

No

Your discounted rate has applied for coupon MJJL
Initial Evaluation: $200/session
Follow-Ups: $125/session

Self Pay Fee Schedule
Initial Evaluation: $300/session
Follow-Ups: $200/session

Who is your Primary Insurance Carrier?

Insurance Carrier Name

Name of person insured

Group Name

ID Number

Please upload an image of your Insurance Card

Select or take picture

Do you have a secondary insurance?

Yes

No

Who is your Secondary Insurance Carrier?

Secondary Insurance Carrier Name

Name of person insured

Employer Name

Group Name

ID Number

Business Address

NOTE: The following links contain very important information regarding your care, your rights and responsibilities as a patient. Please read these documents before signing.

I, have read and agree to the Informed Consent For Assessment And Treatment

I, have read and agree to the Telehealth Services Informed Consent

I, have read and agree to the Authorization to Bill Insurance

I, have read and agree to the Notice Of Privacy Practices

I, have read and agree to the Payment Policy

I, have read and agree to the Acknowledgment of Self-Pay Status

I, have read and agree to the Private Pay Acknowledgement - TMHP Clients

Please upload a picture of an identification card (eg Driver's license, , Passport, etc)

Select or take picture

Please upload a picture of yourself (we need this to verify your identity)

Select or take picture

Please draw your signature below

Sign Here