Complete the Registration Form

For any questions call
(800) 913-2615

Registration And Scheduling Process

01. Registration Form

Fill out the registration form. Please either scan or take a picture of the front and back of your insurance card. You will be asked to upload the images during the registration process. Accepted file formats are jpg, jpeg, png, or pdf.

02. Kaiser Permanente Members – Only

Kaiser Permanente members please note that you need to obtain a referral from Kaiser before completing the registration process.

03. Submitting The Form

Usually within 3 business days, after submitting the form, a patient care coordinator will contact you to review and verify your information.

04. Patient Coordinator

The patient coordinator will schedule an initial assessment appointment.

05. Appointment

You will be provided a behavioral health questionnaire which we ask you to fill out prior the your initial assessment appointment.

06. Treatment Recommendations

A clinician will conduct the initial assessment and make treatment recommendations.

07. New Appointments

New appointment(s) will be scheduled.


Registration Form

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Demographic information

What is your gender?

Choose as many as you like

Parent/Guardian Information

Relationship to patient

Emergency Contact


What service are you looking for?

Have you been hospitalized within
the last 60 days?

Scan Insurance Card

PNG and JPG Formats Allowed.

PNG and JPG Formats Allowed.

Documents for Signature

I acknowledge I have read and understood the content of the forms.

Signature Save

Consent for treatment

Consent for Services using Telehealth

Consent for Release of Information

Healthcare Rights

Insurance Agreement

Cancellation Policy

Registration Form

We Provide Comprehensive Mental Health Services

Health Insurance 101

Understanding health insurance and insurance billing can be tricky. Below you can find answers to some general questions.

The annual deductible is the amount paid out of pocket by the policy holder before an insurance provider will pay any expenses. In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments. The deductible will generally reset once a year and for most the plan year resets on January 1st. There may be different deductible amounts for in-network vs out-of-network.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. There may be a different percentage for in-network vs out-of-network.

A co-pay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed. It must be paid before any policy benefit is payable by an insurance company.

The out-of-pocket maximum is the most you may have to pay for covered services in a plan year. After this amount has been spent on deductibles, copayments, and co-insurance, your insurance plan pays 100%s of the costs of covered benefits.

A type of health insurance plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or no discounted charges from the providers.

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.