Minor Intake | Brain Health USA

Patient's Name *

First

Last

Date Of Birth *

Phone Number *

Email

Current Address *

Address Line 1

City

State

Zip Code

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

Click or drag a file to this area to upload.

Front and back of the Insurance card

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

Do you have secondary insurance?

Insurance Name

Insurance ID

Please upload Front and back of the Insurance card *

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

Pharmacy Name *

Pharmacy Address *

Address Line 1

Address Line 2

City

State

Zip Code

What Service are you interested in? *

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? *