Description of presenting problems – Adult SR

Company

ADULT

This form will only take 2 ~ 4 minutes to complete, however you should take has long as you need to describe your concerns as specific and detailed as you can. This description will help your doctor to select the tests that are needed to provide you with the sound assessment and will ensure appropriate insurance coverage.

Today's date *

First Name *

Last Name *

Date of birth *

Age *

Have you been evaluated in the past 10 years? *

No

Yes

1st question

2nd question

What have you done so far to deal with this issue?

Ex.: I have started therapy when i was 12 for 1 year, then again when i was 17 but it did not work. So my physician put me on Medication but i still believe there is something wrong with me. (To see an example click here)

3rd question

Accepted Insurances:

Anthem Blue Cross
Blue Cross Blue Shield
Aetna / Meritain Health
CalOptima
CareMore
Cigna / Cerner Health Plans
LA Care / Beacon
Care 1st / Pacific Care
Blue Shield of California
Health Net / MHN
Magellan
Tricare/Triwest
Beacon / Value Options / CHIPA
Medicare
Medi-Cal / Medi-Medi / Cal MediConnect

Pasadena Office

(Los Angeles County)

Location: We are locate in the heart of Pasadena, at the crossing of Colorado blvd & Madison Ave, right in front of Earth Cafe.

Address: 790 E. Colorado Blvd, 9th floor, Pasadena, CA, 91101

Direction (car):
– From 210 East, 134 East, 210 West: exit on Lake Ave.

– From 110 North: the freeway ends on S. Arroyo Pkwy. Stay on S. Arroyo Pkwy until you reach Colorado Blvd.

Direction (bus):
– 181, 180, 10, 256, 686, 687

Direction (metro):
Metro Goldline, get off at Lake station. Walk to Lake & Colorado Blvd, then keep walking on Colorado Blvd to the civic 595.

Huntington Beach Office

(Orange County)

Location: We are locate in in one of the most desirable city in the US, a preferred destination of writers, scientists and young people. We are few minutes away from one of the most beautiful coast of the pacific ocean.

Address: 16787 Beach Blvd, Huntington Beach, CA

Direction (car):
- From 405 South: take exit 16, then drive on Beach Blvd.

- From 405 North: take exit 16, then drive on Beach Blvd.

Direction (bus):
- 29A

Hours

We are open Monday through Friday, from 7:00 am to 7:00 pm. Saturday and Sunday's from 8:00am to 2:00 pm.

Parking:

Free street parking for 1 hr, 2 hrs, and 4 hrs available throughout the day.

People with disability: reserved spaces close to all the building entrances.

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