Skip to content

(661) 299-7087 | Saturday Telepsychiatry Appointments Available

HOME
ABOUT US
WHO WE TREAT
- Children
- Teens
- Adults
- Veterans
WHAT WE TREAT
SERVICES
FOR PATIENTS
- News
- Resources
- Events
FOR PROFESSIONALS
CONTACT

626-696-8253

(661) 299-7087 | Saturday Telepsychiatry Appointments Available

HOME
ABOUT US
WHO WE TREAT
- Children
- Teens
- Adults
- Veterans
WHAT WE TREAT
SERVICES
FOR PATIENTS
- News
- Resources
- Events
FOR PROFESSIONALS
CONTACT

Appointment Request Form for California Clients

Complete the form below to submit your request

Welcome Message

Congratulations in taking the first step to start your journey at New U Therapy Center & Family Services!

Here is a positive affirmation for you: you are one step closer, keep going, you deserve it! 🙂

Here are the instructions for your journey:

1. As a first step, please fill out this registration form and submit it as soon as possible.

2. Once we receive it, we will verify your insurance within 24 hours, and we will send you additional consent

paperwork to submit before we schedule your appointment.

3. If you need any assistance in filling out your paperwork, please call us at 818-600-2034 or email us at

info@newutherapy.com and we will happily help you on the spot to fill out the paperwork together.

Now take a deep breath and your journey to becoming a New U is starting now!

Patient contact information

First Name *

Last Name *

Phone *

Email Address *

Who is this appointment for? *MyselfSomeone else

Person filling out form:

Relationship to Patient: *

First Name *

Last Name *

Phone *

Email Address *

Is patient a minor? *YesNo

Parents' marital status: *MarriedDivorcedSeparated

Who has legal custody of the minor? (Legal custody refers to who is able to make decisions about the minor's health appointments and care.) *MotherFatherBothGuardian

Minor lives with *MotherFatherBothGuardian

Parent/Guardian 1 Name *

Relationship to the patient *

Date of Birth *

Street Address *

City *

State *

Zip code *

Email *

Phone number *

Preferred method of contact: *CallTextEmail

Parent/Guardian 2 Name

Relationship to the patient

Date of Birth

Street address

City

State

Zip Code

Email

Phone Number

Preferred method of contact:CallTextEmail

Please attach all legal custody order paperwork indicating the legal custody arrangement of the minor here if the parents are divorced or legally separated. We will not be able to schedule an appointment without the paperwork. All pages must be included: *

No file chosen

DOB *

Administrative Sex: *MaleFemaleOther

Gender Identity: *HeSheTheyOther

Social Security Number: *

Patient Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Can we leave a message? *YesNo

Preferred method of contact: *Cell PhoneEmail

Please describe the reason for your visit: *

Who referred you to New U Therapy? *

May I thank them? *YesNo

Referrer Phone Number: *

Select *

PsychiatryPsychotherapyIOP/PHPWeekly Group Therapy for AdultsKetamine-assisted psychotherapyNot Sure

Primary Health Insurance Information:

Insurance Company: *AetnaAnthem Blue Cross CommercialAnthem Blue Cross MedicalBlue Shield CaliforniaCarelon - CommercialCignaComPsychHeritage/LakesideLYRAMagellan CommercialMedicareMHN CommercialHealth Net Medi-CalMultiPlanOptumTriwestTricare

ID Number: *

Group ID Number: *

Primary Insured Name: *

Date of Birth *

Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Social Security Number: *

Insurance Plan Type: *PPOHMOEPOPOSIPA

Relationship to the primary subscriber *

Insurance contact number *

Address to Submit the Claims *

Attach a copy of the front and back of your primary insurance ID card: *

No file chosen

Do you have Secondary Health Insurance? *YesNo

Secondary Health Insurance Information (if applicable)

Insurance Company: *AetnaAnthem Blue Cross CommercialAnthem Blue Cross MedicalBlue Shield CaliforniaCarelon - CommercialCignaComPsychHeritage/LakesideLYRAMagellan CommercialMedicareMHN CommercialHealth Net Medi-CalMultiPlanOptumTriwestTricare

ID Number: *

Group ID Number: *

Primary Insured Name: *

Date of Birth: *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Social Security Number: *

Insurance Plan Type: *PPOHMOEPOPOSIPA

Relationship to the primary subscriber *

Insurance contact number *

Address to Submit the Claims *

Attach a copy of the front and back of your secondary insurance ID card: *

No file chosen

Attach a copy of the front of your government-issued photo ID: *

Drag and Drop (or) Choose Files

Primary Care Physician Information:

Name *

Email Address *

Phone *

I authorize New U Therapy to discuss my treatment with the individual listed above: *YesNo

Name of Pharmacy *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Primary Care Physician Information:

Name *

Email Address *

Phone *

I authorize New U Therapy to discuss my treatment with the individual listed above: *YesNo

Name of Pharmacy *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Emergency Contact Information

Name *

Phone *

Relationship to the patient *

authorize New U Therapy to discuss my treatment with the individual listed above in an emergency *Yes

By signing my name below, I am acknowledging that the information provided is true, correct and complete to the best of my knowledge. *Yes

Patient/Guardian signature *

Thank You

New U Therapy Center & Family Services

Valencia, CA: 25000 Avenue Stanford, Suite 167 Valencia, CA 91355

Westlake Village, CA: 31200 Via Colinas, St 202, Westlake Village, CA 91362.

Torrance, CA: 3812 Sepulveda Blvd # 260, Torrance, CA 90505

Submit your inquiry for services. For providers to apply an inquiry about a carrier, apply here

Phone: (661) 299-7079

Email: info@newutherapy.com

Privacy Policy

Find Us On Google

New U Therapy Center | Psychiatry & Ketamine Assisted Psychotherapy, Valencia, CA

New U Therapy Center & Family Services, Westlake Village, CA