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Client Information Form

Client Information

Perhaps you have never seen a mental health professional and you are feeling stressed, anxious, struggling to get a good night of sleep. Or perhaps you recently moved to LA and are looking to establish care with a new mental health professional. Whatever the reasons may be - please let us know. And don't be concerned about writing too much - the more info - the better. It's important to note that if you are making the appointment to secure paperwork - NO PAPERWORK WILL BE COMPLETED DURING THE FIRST TWO VISITS. People likely to benefit from their experience with our group are typically interested in establishing an ongoing relationship focused on improving their overall health and happiness. If you are primarily interested in disability paperwork or a service animal letter our group is not an appropriate match.
In order to use Zoom to meet with your clinician virtually, you will need a computer or smartphone and a reliable internet connection. Our client support team will also do a test video-chat with you to confirm your equipment and internet connection work, prior to scheduling you for a virtual session with a clinician. Additionally if you are new client and your physician determines that you would benefit from a controlled substance medication prescription, you will have to have an in person visit first.
If you are interested in Couples Counseling, please enter the name of your partner that will participate in Couples Counseling. In order to schedule you and your partner for Couples Counseling, your partner will have to register as a client, completing registration and signing the payment policy as well.
Enter your date of birth in this format: MM / DD / YYYY.

Payment - Primary Insurance Information

Identify the healthcare insurance you are using. If you are not using insurance, simply select the option that says I'm not using insurance and am paying myself.
NOTE: Contact your insurer directly by calling member services on the back of your insurance card to confirm what your mental health benefits are and understand what your financial responsibility is. You should ask them to explain your "outpatient mental health benefits" to you. If you have Blue Shield or Blue Cross / Blue Shield please contact your insurer directly and confirm who your mental health benefits are provided by. Our group does not participate as an in network provider with Magellan insurance.
Drop a file here or click to upload Choose File
Maximum upload size: 104.86MB
Drop a file here or click to upload Choose File
Maximum upload size: 104.86MB

Secondary Insurance

Secondary Insurance Information

If you have secondary insurance information, please enter that information here.
Drop a file here or click to upload Choose File
Maximum upload size: 104.86MB
Drop a file here or click to upload Choose File
Maximum upload size: 104.86MB

Your Preferred Pharmacy

All prescriptions are handled electronically. Please indicate the Pharmacy Name, Address and Phone Number, so that we have your pharmacy on file. Only the pharmacies on this list have demonstrated that they can reliably accept all electronic prescriptions.

Referral Information

If you were NOT referred by a Physician, please enter NONE

Parent / Spouse / Partner - Subscriber Details

If you are covered under someone else's insurance, such as your parent, spouse or partner or you are a parent bringing your child to the Genen Group please provide the information below - it is required. The information below refers to who the subscriber to the insurance plan is, ie your parent, spouse or partner, or yourself if you are the parent bringing a minor for an appointment.

All information is transacted using 256 bit encryption via a SSL connection.

Once you successfully click Submit, you will be redirected to review and complete our Policies. After we receive your registration information and signed policies we’ll confirm an appointment for you.

We have taken great effort to develop client-focused processes that ensure transparency, efficiency and optimize client satisfaction and outcomes. We hope to exceed your expectations and make all of your appointments, starting with your first one, as convenient, relaxing and stress-free as possible.