Patients Name *

First

Last

Date Of Birth

Phone Number *

Email

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload Copy of Guardian’s ID (Driver License/Passport)

Click or drag a file to this area to upload.

Do you have secondary insurance?

Insurance Name

Insurance ID

Front and back of the Insurance card

Click or drag files to this area to upload. You can upload up to 2 files.

Which state do you reside? *

Your medication will be delivered to your home within 24 hours from our partner pharmacy free of charge.

King plaza Pharmacy
7227 Van Nuys Blvd, Van Nuys, CA 91405
+1 (800) 525-1454

Pharmacy name

Pharmacy address

Address Line 1

Address Line 2

City

State

Zip Code

Are you seeking therapy or psychiatry? *

Are you intrested in our tele-health partial teen program ( Ages between 12-17, not covered by insurance?) *

For an more tailored and comprehensive treatment plan
will need comprehensive treatment plan. our goal is to tailored a mental health treatment plan that is then designed to address the specific disorder and its unique feature including evidence-based psychotherapy, family-focused therapy, peer support groups, medication management, holistic therapies, and experiential activities to achieve an overall treatment goal and mental remission.
Common Examples of mental health disorders in this age group include anxiety disorders, depression, bipolar disorder, and some personality disorders.

In conclusion this program is

Timed ( 6 weeks)
Measurable ( psychological testing and treatment goal)
Parents are involved
Care plan and goals should be met or reevaluated.
Coping skills, behavioral therapy and coaching development are being incorporated to achieve long term remission success.

Do you attend the regional center for autism or intellectual disability? *