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Client Portal

HOME
LOCATIONS
ABOUT
THERAPY AT HTG
BLOG
LINKS & RESOURCES
CONTACT
Client Portal

New Client Intake

New Client Intake

Welcome to Heredia Therapy Group's self-referral page! Congratulations! By visiting this page you have taken the first step necessary to receive the help that you deserve! We understand that sometimes it may be daunting to pick up the phone and call, so fill out this form, and a trained member of our team will be reaching out to initiate services.

"*" indicates required fields

I am completing this form...*

Parents*

Do you require language assistance?*

Yes

No

Which Language*

How did you hear about Heredia Therapy Group?*

If other, please indicate how:*

Which office are you referring from*

If other, please indicate how:*

Child's Date of Birth*

MM slash DD slash YYYY

Client's Date of Birth*

MM slash DD slash YYYY

Services Interested In*

Mental Health - Individual Counseling

Mental Health - Couple's Counseling

Mental Health - Family Counseling

Applied Behavioral Analysis (ABA)

Occupational Therapy (OT)

Autism Evaluation

ADHD Evaluation

Cognitive Evaluation

Client's First Name*

Client's Last Name*

Phone Number:*

Secondary Phone Number

Client's Email*

Parent's Email*

Client's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How would you like to cover your services?*

What is your budget for services?*

Please expand*

i.e. Victims of Crime (V.O.C), HSA Card, Etc.

Are you a member of Medi-cal?*

Yes

No

Do you know your CIN number? Please enter it below*

If not, please indicate by stating "I don't know"

Health Insurance Name*

You indicated an insurance that we are currently at capacity with. Please note, that Heredia Therapy Group may be able to use other insurance avenues, and will let you know the result.*

I Understand

Name of "other" Insurance*

Please note that if Heredia Therapy Group is not in network with your insurance provider, we will exhaust all resources to verify if we can or cannot see you through your insurance carrier.

Insurance Member ID*

Upload a copy of your insurance card*

Max. file size: 256 MB.

Clinical Demographics

Have you been a client at Heredia Therapy Group before?*

Yes

No

What services have you received in the past*

Mental Health - Individual Counseling

Mental Health - Couple's Counseling

Mental Health - Family Counseling

Applied Behavioral Analysis (ABA)

Occupational Therapy (OT)

Psychiatry

Autism Evaluation

ADHD Evaluation

Cognitive Evaluation

Do you remember the name of your previous therapist(s)*

Yes

No

Not Sure

Name(s)*

Does another member of your immediate or extended family receive services at Heredia Therapy Group?*

Yes

No

Name(s) of family members*

We ask for this information to protect your confidentiality, and prevent the same family member from receiving services with the same therapist.

Reason for seeking services (i.e. depression, anxiety, ASD, medication management) Please be as detailed as possible.*

Availability for ongoing services*

Are you actively suicidal, or have had suicidal thoughts?

Yes

No

If yes, please explain.*

When did you last have thoughts. What are the frequency of the thoughts, etc.

Have you ever been hospitalized for any psychiatric or psychological reasons?

Yes

No

If yes, please explain.*

be sure to include the date of the last hospitalization, duration of the hospitalization, discharge recommendations.

Please include the discharge documentation

Max. file size: 256 MB.

You can upload it here, or you will be asked to upload at a latter time.

Are you currently taking any non-prescribed medications or substances?

Yes

No

If yes, please explain.*

i.e. drinking alcohol, marijuana, vaping, etc

Do you have a history of taking any non-prescribed medications or Substances?

Yes

No

If yes, please explain.*

i.e. drinking alcohol, marijuana, vaping, etc

Adolescent Particulars

Is there a current custody agreement in place for your child?*

Yes

No

Point of Contact/ Pertinent Information*

You will be asked to provide the office with a current copy of your custody documentation. You can upload the documentation here to help expedite the process, or you can provide it to the office at a latter time.

Max. file size: 256 MB.

Do you have a history of Mental Health Services? If so, what were the outcomes?*

Do you have a history of Occupational Therapy Services? If so, what were the outcomes?*

Do you have a history of Psychiatric Services? If so, what were the outcomes?*

Do you have a history of ABA Services? If so, what were the outcomes?*

Are you seeking online or in-person services?*

Do you have a formal ASD, ADHD, or similar diagnosis from a clinical psychologist?*

Yes

No

If not, Heredia Therapy Group may be able to provide this service for you as well, if your insurance requires it!

Which Location?*

Additional Questions

Please note, that Heredia Therapy Group does not get involved in any legal cases. You will be asked to sign the disclosure upon completion of intake.

Are you involved in any active restraining order cases*

Yes

No

If yes, please explain.*

Are you involved in any active court cases?*

Yes

No

If yes, please explain.*

Will there need to be any external communication?*

Yes

No

i.e. with Lawyers, Social Workers, DCFS, etc?

If yes, please explain.*

Please indicate below the best time(s) to reach you by phone.*

Please note, that our administrative office is only open M - F until 5:00 pm

Preferred method of communication*

Please note, that although your preferred method of communication is not phone call. Heredia Therapy Group may contact you via phone to confirm the information provided is accurate. As such, please indicate some time below the best time(s) to reach you by phone.*

Communication and scheduling through text message is not an approved form of communication, and as a result, will only be used for appointment reminders.

Phone

This field is for validation purposes and should be left unchanged.

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