Intake Form

Intake Forms


Thank you for trusting us with your healthcare needs; we look forward to meeting you and hope to exceed your expectations in every aspect of your behavioral treatment. Each employee at Pasadena Clinical Group is committed to enhancing the quality of your care and your overall experience. Filling out the form below will help us get acquainted with your medical history and help your therapist to target your plan. 

Complete the form in each part to the best of your knowledge. Upon submission, our staff reviews it in 1 to 4 hours (during business hours). We may have to reschedule your appointment if anything is incorrect or missing. 

If you are covered by two insurance plans, such as through your job and your spouse's job, or if you have Medi-Medi, you need to attach a copy of both insurance cards.

If you have a copay, you will need to pay it at the time of the visit, with no exceptions. 

You will need a copy of your Driver's License (or any other government-issued ID), and a copy of your insurance card. 

All attachments must be in PDF, JPG, or HEIC format. We cannot accept emails or other means of verification.

You can follow this check-list for your convenience:

    1. Driver's License or a government-issued ID
    2. Copy of all your insurance cards
    3. Referral from your psychiatrist or primary care physician (if available)
    4. Copy of any previous evaluations, including school-based assessments (if available)

There are three ways to access the Intake form:

  • QR Code

  • On-line completion (see below)

Please set aside 6 to 8 minutes to complete the form. 

Should you have any questions, please do not hesitate to contact our office for help at 626-354-6440, Monday through Friday, from 8 am to 7 pm.