Orange County, CA Concierge Psychiatry, Psychotherapy
& Medication Management
At South Coast Psychiatry, we request that you complete these forms prior to your initial consultation. Both the forms themselves, as well as a short description of each of the forms, are provided here.
Please download the forms, print them out, fill them out, and bring them with you to your initial consultation.
If you have any difficulties downloading or printing the forms, they can be emailed or we can mail a hard copy to you, depending on your preference, upon scheduling your initial consultation.
If you are unable to receive the forms in advance of your session, please plan on arriving 15-20 minutes early to your scheduled initial appointment so that you can fill out the paperwork prior to your first visit.
Your psychiatrist or therapist will review these forms and the information you provide at your first visit, as well as answer any additional questions you may have.
An email of the forms will be sent to you so you can download the forms onto your computer. If you have any difficulties downloading or printing the forms, please let our office know.
Treatment Information and Authorization:
This form provides you with information about treatments that may be offered to you, including psychotherapy and/or medication(s). Please read the information carefully, and sign the authorization prior to your first visit at South Coast Psychiatry.
Patient Information Form:
This form provides your doctor with more information about you, your reasons for seeking treatment, and other relevant details prior to your first visit.
HIPAA Patient Privacy Notification:
This serves as your notification of your rights to privacy, under the Health Care Information Portability and Accountability Act. Please print out this notification and keep it for your own records.
Receipt of Privacy Notification Form:
Please sign this form to indicate you have received a copy of the HIPAA Patient Privacy Notification and bring it to the initial visit for inclusion in your chart.
Consent for Release of Information:
Please fill out this form if you have another doctor or therapist, or friend or family member, whom you would like your doctor to contact to obtain or give information about your diagnosis, treatment, prognosis, etc. You can specify to whom the information should be released, and what type of information can be shared. At South Coast Psychiatry, we believe in close cross-collaboration between treating clinicians (i.e., having your psychiatrist and psychologist talk about your care) and in coordination of primary care and psychiatry. Having a Consent for Release of Information form allows your psychiatrist or therapist to provide you the best integrated care possible.
At South Coast Psychiatry, we do not take any type of insurance and our doctors are considered out-of-network providers for all insurance panels. We will not bill your insurance directly for any services. However, we will provide you with a receipt for any services provided so that you may bill your own insurance for whatever reimbursement they will provide. Although we will not be billing your insurance directly, some patients do go through their insurance for medications, which often requires additional authorization from our office. Having your insurance information on file will make it easier for our office to expedite any of these requests.
Credit Card Authorization:
When you make an appointment at South Coast Psychiatry, we will block that time out for you in your clinician's schedule, and in return request that you fill out a credit card authorization form. Your card will only be charged in the event of a cancellation less than 48 business hours in advance of your appointment, or for any services rendered (telephone session, report writing, etc.) without payment provided at the time of service.
Telemedicine Consent Form:
In the event that our patients are out of town, or unable to come to their appointments, our clinicians can conduct phone sessions with them, so the treatment and support can continue without interruption. This form gives your consent to speak by phone with our clinicians.