New Patients
Acknowledgment of Receipt Notice of Privacy Practices
Acknowledgment of Receipt Notice of Privacy Practices (Spanish)
Medical Release
Medical Release (Spanish)
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)
Patient Information - Adults
Patient Information - Adults (Spanish)
Patient Financial Responsibility Form
Patient Financial Responsibility Form (Spanish)
Sliding Fee Discount Schedule - 2023
Sliding Fee Discount Scehdule - 2023 (Spanish)
Sliding Fee Discount Application
Sliding Fee Discount Application (Spanish)
Existing Patients
New Patients
Acknowledgment of Receipt Notice of Privacy Practices
Acknowledgment of Receipt Notice of Privacy Practices (Spanish)
Authorization Caregiver-Guardian
Authorization Caregiver-Guardian (Spanish)
Medical Release
Medical Release (Spanish)
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)
Patient Information - Pediatrics
Patient Information - Pediatrics (Spanish)
Patient Financial Responsibility Form
Patient Financial Responsibility Form (Spanish)
Sliding Fee Discount Schedule - 2023
Sliding Fee Discount Schedule - 2023 (Spanish)
Sliding Fee Discount Application
Sliding Fee Discount Application (Spanish)
Existing Patients
2023_Sliding_Fee_English.pdfNew Patients
Acknowledgment of Receipt Notice of Privacy Practices
Acknowledgment of Receipt Notice of Privacy Practices (Spanish)
Authorization for Caregiver/Guardian (English and Spanish)
Health History Form - Adult
Health History Form - Adult (Spanish)
Health History Form - Pediatric
Health History Form - Pediatric (Spanish)
Medical Release
Medical Release (Spanish)
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)
Patient Information
Patient Information (Spanish)
Patient Financial Responsibility Form
Patient Financial Responsibility Form (Spanish)
Sliding Fee Discount Schedule - 2023
Sliding Fee Discount Schedule - 2023 (Spanish)
Sliding Fee Discount Application
Sliding Fee Discount Application (Spanish)
New Patients
Acknowledgment of Receipt Notice of Privacy Practices Form
Acknowlegement of Receipt Notice of Privacy Practices Form (Spanish)
Authorization for Behavioral Health and PCP to Share Confidential
Information Form
Authorization for Behavioral Health
and PCP to Share Confidential Information Form (Spanish)
Behavioral Health Office Policy and Consent for Treatment
Behavioral Health Office Policy and Consent for Treatment (Spanish)
Consumer Information
Consumer Information (Spanish)
Notice to Clients
Notice of Privacy
Practices Form
Notice of Privacy Practices Form (Spanish)
Patient Information
Psychotropic Medication Consent
Patient Financial Responsibility Form
Patient Financial Responsibility Form (Spanish)
Sliding Fee Discount Schedule - 2023
Sliding Fee Discount Schedule - 2023 (Spanish)
Sliding Fee Discount Application
Sliding Fee Discount Application (Spanish)
Our mission is to provide access to affordable, quality medical, dental, and behavioral health care services to all residents of Southern California communities, especially the vulnerable populations.
