Hernandez Counseling & Associates

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Address

Enter full address

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Have been seen at this office before?

If YES, who was your provider? If NO, type N/A

Have you been working with someone in our office regarding the services you are requesting?

If YES, who have you been communicating with? If NO, type N/A

Is your treatment request related to a workers compensation case, unemployment case, disability claim, court ordered or a legal or potentially legal case?

If YES, provide details. If NO, type N/A

Limited to 600 characters

Is this treatment for a minor (18 or younger)?

For Couples treatment: Is there an active restraining order, court order or social worker involvement?

Explain in detail - Type N/A if not applicable

Limited to 600 characters

Billing & Payment

Payment method

How do you plan to pay?

Who is your insurance carrier?

If you don't plan on using insurance type N/A

Do You have multiple Insurances?

If YES, what are all your insurance carriers? If NO, enter N/A.

If you have Medi-cal, is it assigned to another insurance carrier?

Example: Medi-cal assigned to LA Care. If NO, type N/A

What is your insurance member ID? f you have more than one insurance, enter all ID numbers.

If not using insurance type N/A

Limited to 600 characters

Social Security Number

Type N/A if you do not have one

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend only Any time

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.