Health Insurance Name* Aetna Anthem Blue Cross Beacon Health Options Beacon Health Strategies Blue Shield of California Blue Shield of California Promise Cal Optima Carelon Cigna Evernorth Behavioral Health Inland Empire Health Plan (IEHP) Kaiser Permanente L.A. Care Managed Health Network (MHN) Magellan Molina Healthcare Optum Tricare-West Other
Frequently, mental health benefits are processed through different insurance panels than the ones listed on your insurance card. If your insurance is not included in this list, please don’t hesitate to seek mental health assistance. Simply choose the “Other” option, and our team will review your benefits to inform you about the available options.
Partner's information Please fill out this section if your partner also has health insurance. If you are both on the same health plan, it is not necessary to fill in this information, and you can leave it blank
Select which option more closely aligns with your situation* My partner has insurance, and I am including their information below. My partner does not have health insurance, I am intentionally leaving the below blank My partner and I are on the same health insurance plan
Please note, that if you are in a domestic partnership, marriage, civil union or other legal relationship, and the insurance provided is not the primary coverage, you may be subject to financial responsibility.
Partner's Health Insurance Aetna Anthem Blue Cross Beacon Health Options Beacon Health Strategies Blue Shield of California Blue Shield of California Promise Cal Optima Carelon Cigna Evernorth Behavioral Health Inland Empire Health Plan (IEHP) Kaiser Permanente L.A. Care Managed Health Network (MHN) Magellan Molina Healthcare Optum Tricare-West Other
If yes, please explain.*
When did you last have thoughts. What are the frequency of the thoughts, etc.
If yes, please explain.*
be sure to include the date of the last hospitalization, duration of the hospitalization, discharge recommendations.
If yes, please explain.*
i.e. drinking alcohol, marijuana, vaping, etc
If yes, please explain.*
i.e. drinking alcohol, marijuana, vaping, etc
You can upload a copy of that report now If you do not have it on hand. No worries, please feel free to submit the form anyways, but please note, that the office will be asking for a copy before proceeding with services.
Which Location?* City of Industry (13200 Crossroads Parkway City of Industry, CA 91746) Downey (10800 Paramount Blvd. Downey, Ca 90241) Corona (495 E Rincon Street Corona, CA 92879) Anaheim (300 S. Harbor Blvd. Anaheim, Ca 92805)