GENERAL FORMS
Please Complete the appropriate form(s) before your first appointment.
Some forms can be downloaded, other can only be completed online. Online submission is the fastest way. If you choose to download and complete your form offline please type in clearly and sign legibly, so your insurance claims are not denied. Also, do not leave any question unanswered: if there is a question that does not apply to your case add NA and explain why it does not apply to you. Once you have filled out the form make a copy for your records, and bring the original with you. Due to the HIPAA (federal) laws we do not accept any form sent by email. If you have any question you can contact us at (626) 354-6440, Mon - Fri 9am - 5pm.
ADULT
| Form # | Form Name | Who must sign it? | ONLINE SUBMISSION | DOWNLOAD | |
|---|---|---|---|---|---|
| ADULT | 013A | Informed Consent | Patient | NO | NO |
| 015A | Notice of Privacy Policy | Patient | NO | NO | |
| 017A | Office Policies | Patient | NO | NO | |
| 019A | Arbitration Agreement | Patient | NO | NO | |
| 021A | HIPPA Receipt | Patient | NO | NO | |
| 023A | Psychological Tests | Patient | NO | NO | |
| 025A | Neuropsychological Test | Patient | NO | NO | |
| 027A | Authorization to disclose | Patient | NO | NO | |
| 029A | Structured Developmental Questionnaire | Patient | NO | NO |
Minor (Parent(s) and Legal Guardian)
| Form # | Form Name | Who must sign it? | ONLINE SUBMISSION | DOWNLOAD | |
|---|---|---|---|---|---|
| MINOR | 013M | Informed Consent | Parent or Legal Guardian | NO | NO |
| 015M | Notice of Privacy Policy | Parent or Legal Guardian | NO | NO | |
| 017M | Office Policies | Parent or Legal Guardian | NO | NO | |
| 019M | Arbitration Agreement | Parent or Legal Guardian | NO | NO | |
| 021M | HIPPA Receipt | Parent or Legal Guardian | NO | NO | |
| 023M | Psychological Tests | Parent or Legal Guardian | NO | NO | |
| 025M | Neuropsychological Test | Parent or Legal Guardian | NO | NO | |
| 027M | Authorization to disclose | Parent or Legal Guardian | NO | NO | |
| 029M | Structured Developmental Questionnaire | Parent or Legal Guardian | NO | NO |
Teachers
| Form # | Form Name | Who must sign it? | ONLINE SUBMISSION | DOWNLOAD | |
|---|---|---|---|---|---|
| MINOR | 013M | Teacher/Educator | YES | NO | |
| 015M | YES | NO | |||
| 017M | YES | NO | |||
| 019M | YES | NO | |||
| 021M | YES | NO | |||
| 023M | YES | NO | |||
| 025M | YES | NO | |||
| 027M | YES | NO | |||
| 029M | YES | NO |