Step 1. Identity Information This form is confidential and HIPAA compliant First Name Last Name Date of Birth Call Back Phone Number E-mail Go back Next What would you like to do? Schedule an Appointment Reschedule Appointment Cancel Appointment Previous Next Will this appointment be for you or are you making a referral for someone else? Myself I am making a referral for someone Will this appointment be for your child? Yes, I am a parent No/Other Parent(s) or Guardian(s) information Name of Parent(s) or Guardian(s) Birth date of Parent(s) or Guardian(s) Parent(s) or Guardian(s) maiden name Patient information Patient's Name Patient DOB Patient's phone number Patient's email address Relationship to the patient Previous Next Please tell us how you heard about us Referred by Doctor or Healthcare Provider Friend or Family Member Google Facebook Church School DCFS Instagram LinkedIn New U Website Yelp Psychology Today Santa Clarita Magazine New U Employee Text "Care" Campaign Insurance Provider Other Previous Next What area are you looking services for? Psychiatry or Medication Management Individual Counseling Couples Counseling Child Psychotherapy Other Previous Next State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming City ZIP-code Gender What is the best time(s) of day to contact you for scheduling? Morning Afternoon Evening May we send you text messages? Yes No School (if child) Previous Next Primary Health Insurance Information If you will be using insurance, what type of insurance do you have? If you have a private or commercial insurance policy, what is your Member ID? If you have a private or commercial policy, what is your group number? Insurance Plan Type PPO HMO Neither What is the phone number on the back of your card for either Provider Services or Behavioral/Mental Health? Previous Next What is the reason for the referral? Psychiatry or Medication Management Individual Counseling Couples Counseling Child Psychotherapy Other What primary concern(s) are you seeking treatment for? Is there anything else we should know before scheduling your appointment? Previous Submit request
