Telehealth Portal

NEW PATIENT FORMS

Mental Health Clinic located in Newport Beach, Laguna Beach and Dana Point, CA

Please complete the following packet entitled 'New Patient Forms' below prior to your initial consultation.

Once completed, please remember to bring them to your appointment.

This will save valuable time and help make the initial session more efficient.

New Patient Forms

New Patient Forms Checklist

ADDITIONAL FORMS

Consent for Evaluation & Treatment / Practice Policies

Provides information about our practice policies and services. Please read carefully.

Patient Information

This form collects important background information.

HIPAA Notice of Privacy Practices

Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act.

Receipt of Privacy Practices

Signing this form indicates that you received a copy of the HIPAA Patient Privacy Notification.

Consent for Release of Information

This form is very important if there are others that need to be contacted regarding your case. Please remember that confidentiality is a pillar of mental health care. Therefore, you are always in charge of who receives information and is included in the treatment process.

Credit Card Authorization

Since we will hold appointment times for you, we request that you fill out this form and always keep an active credit card on file with the office.

Telemedicine Consent Form

This form outlines specific issues pertinent to telemedicine services.

Adult History Form

This form collects important background information for testing.

Child History Form

This form collects important background information for testing.

Mind Health Institute, Orange County

✆ Phone (appointments): 949-891-0307

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