For clients’ convenience, here are forms associated with sessions at Wilshire/Valley Therapy Centers. All forms are submitted securely online and are HIPPA compliant.
Patient Intake Form (PIF): In-person office visit.
Telemedicine intake form (TIF): Online teleheath visit.
Spanish-language intake form: For in-office and telemedicine sessions.
Special pricing packages: Wilshire/Valley offers discount pricing for multiple therapy sessions when package is paid in advance. Use this form to order session packages or individual sessions.
Payment form: Credit card information for co-payments and other fees (paying down deductibles, no-shows or late cancellations). (Client will be notified prior to charging card for no-show or late-cancellation fees.)
Insurance information: Proof of coverage.
Release of information form: Allows therapist to communicate
with specifically named persons or entities (a doctor or teacher, etc. ). Also: Download PDF version of confidential info form.
Medical records request form: For providing treatment information to outside parties such as your doctor.
Standard of care release: Authorizes insurance company to receive summary of treatment record and notes.
Couples consent form: For therapy.
Telemedicine informed consent form: For online therapy.
Family consent form: For therapy.
Teen-parent consent: Adolescent agreement to therapy privacy policies.
Minor consent form: Parental permission for psychotherapy treatment of a minor. In office or telemedicine.
Family history: To be shared with your therapist to assist in meeting your mental-wellness goals. Optional and confidential.
Collateral declaration: For one-time support sessions.
EMDR disclaimer: Informed consent for EMDR treatment.
Court documents: To verify legal custodial agreement.
Client feedback: Let Wilshire/Valley know if you have an issue or just a comment about its services. Good or bad.
Event signup and payment: For Wilshire/Valley events and courses.
Anthem grievance form: For member complaints. Print out and mail to Anthem at provided address.