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Green Hills with Blue Sky
Fremont Office
39210 State Street, Suite 200
Fremont, CA 94538
(510) 896-8958
Santa Cruz Office
343 Church Street
Santa Cruz, CA 95060
(831) 621-1150

Intake Form and Consent Forms

We are looking forward to meeting with you and starting the treatment plan that you have been waiting for. Prior to coming in for your first intake appointment, we need to obtain some preliminary information in order to start your treatment program. 

Once you complete each form, hit the "submit button" which will ensure direct delivery to our center via confidential and encrypted data transmission which is HIPPA compliant. 

If you have any questions about the consent forms, please don't hesitate to call the clinician that you are scheduled to see, or just bring your questions to your first appointment. 

We need your intake and consent forms signed prior to your first appointment. 

Intake Form

Consent to Use and Disclose Health Information

Confidentiality Form

Consent to Treatment

Financial Agreement Form

Schedule A Free Consultation

Santa Cruz Center: (831) 621-1150
Fremont Center: (510) 896-8958