• HOME
  • LOCATIONS
  • ABOUT
    • BOARD OF DIRECTORS
    • Mental Health Clinicians
      • City of Industry
      • Downey
      • Corona
      • Anaheim
      • Remote Therapists
    • ABA Team
  • THERAPY AT HTG
    • Counseling Services
      • Individual Counseling
        • Adult Therapy
        • Teen Counseling
        • Child Therapy
        • Child Play Therapy
    • Mental Health
      • Therapy for Depression
      • Therapy for Anxiety
      • Therapy for Trauma
    • ABA THERAPY
    • Social Skills Groups
    • Telehealth Services
    • LGBTQIA+ Therapy
  • BLOG
  • LINKS & RESOURCES
  • CONTACT
  • Client Portal

Heredia Therapy Group

Provide us with your feedback!

At Heredia Therapy Group, it is our goal to ensure that everyone seen, heard, and valued. The purpose of this forum is to provide our quality assurance team with honest and transparent feedback regarding your sessions! Anonymity is kept at utmost priority, and your personal identity will not be shared with your clinician whatsoever. 

Haga clic aquí para español

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

You will fill out the child's information below under "Demographic information"
You will fill out the child's information below under "Demographic information"
Are you looking for therapy in a language other than English? OR do you require language assistance?*
MM slash DD slash YYYY
MM slash DD slash YYYY
Services Interested In*
Select one or all services that you might be interested in.

Demographic Information

Or Parent's
Client's Address*
i.e. Victims of Crime (V.O.C), HSA Card, Etc.
Are you a member of Medi-cal?*
If not, please indicate by stating "I don't know"
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.
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
Max. file size: 256 MB.
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. Often times insurance benefits are ran through multiple insurance partners, and we can do the digging for you!
Max. file size: 256 MB.
Verification of benefits is not a guarantee of coverage or payment from your insurance company. Coverage and payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service.*

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
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 Name*
MM slash DD slash YYYY
Is your partner a member of Medi-cal?
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.
Max. file size: 256 MB.

Clinical Demographics

Have you been a client at Heredia Therapy Group before?*
What services have you received in the past*
Do you remember the name of your previous therapist(s)*
Does another member of your immediate or extended family receive services at Heredia Therapy Group?*
We ask for this information to protect your confidentiality, and prevent the same family member from receiving services with the same therapist.

What is your availability for ongoing services.

Once your insurance is verified, When are you available for weekly sessions. Please keep in mind that our Mental Health services are typically scheduled one time per week at the same day and same time. We do not offer Monthly sessions. Additionally, for our ABA services, these occur at minimum 3 times per week in home or in office.
Mondays*
Tuesdays*
Wednesdays*
Thursdays*
Fridays*
Saturdays*
Sundays*
Are you actively suicidal, or have had suicidal thoughts?
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?
be sure to include the date of the last hospitalization, duration of the hospitalization, discharge recommendations.
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?
i.e. drinking alcohol, marijuana, vaping, etc
Do you have a history of taking any non-prescribed medications or Substances?
i.e. drinking alcohol, marijuana, vaping, etc

Adolescent Particulars

Is there a current custody agreement in place for your child?*
Max. file size: 256 MB.
Do you have a formal ASD, ADHD, or similar diagnosis from a clinical psychologist (PsyD or PhD only)?*
If not, Heredia Therapy Group may be able to provide this service for you as well, if your insurance requires it! Please note, that a school psychologist or regional center evaluation is not accepted by insurance panels.
Max. file size: 256 MB.
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.

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*
Are you involved in any active court cases?*
Will there need to be any external communication?*
i.e. with Lawyers, Social Workers, DCFS, etc?
Please note, that our administrative office is only open M - F until 5:00 pm
Communication and scheduling through text message is not an approved form of communication, and as a result, will only be used for appointment reminders.
This field is for validation purposes and should be left unchanged.
Please input the date of birth of the client that is receiving services with Heredia Therapy Group. This will allow us to link the form to their file

To schedule, please complete this authorization. This form is HIPAA Compliant, and stored on your file. Charges for missed appointments are not covered by insurance and are your sole responsibility. Your credit card will be charged if you fail to show or cancel less than 24 hours in advance of a scheduled appointment. This credit card will be used for copays or coinsurance rate for attended appointments. If you do not show up for your scheduled appointment and have not notified us at least 24 hours in advance, you will be charged to the credit card listed below. If you miss a scheduled appointment without contacting the office, all future appointments will be cancelled in our system, and you are responsible for initiating rescheduling. We realize that clients may need to cancel or change their appointments from time to time. If you must do so, please contact our office by calling 562-821-1491 and leaving a voice message at least 24 hours before your scheduled appointment time. If you miss three appointments with less than 24 hour notice a referral may be provided.

Credit Card Information:

As it is written on your card
As it is written on your card
Billing Address:(Required)

Authorization

Authorization: I understand and agree with the above stated policy regarding placing my credit card information on file and I hereby authorize Heredia Therapy Group to charge my credit card accordingly as outlined above.
<meta charset="utf-8" </head><title>
  • HOME
  • BLOG
  • CONTACT
  • Privacy Policy
  • Join our Team

Heredia Therapy Group Site Powered by Pix & Hue.