New Patient Form

Patient Information:

Preferred Contact Number(s)

Consent to Leave Detailed Message

Consent to Text Message

Consent for staff to email you


LAST 4 of SSN#

Health Insurance

Preferred Pharmacy

Collaboration of Care (This may include but is not limited to diagnosis, medication, recommendations)

Emergency Contact

Patient / Patient Representative / Guardian Signature


Confidentiality & Reporting: While one of the clinician's primary duties is to protect the patient's privacy and confidentiality, this duty is not absolute or without exceptions. Communications are confidential and generally no information will be released without your consent, except for the following. Inner Balance Psychiatry & Wellness Inc. clinicians are considered mandatory reporters for child abuse and dependent adult/elder abuse. Clinicians may also have charts subpoenaed in legal cases however records may be subject to patient-clinician privilege and patient confidentiality/safety is of utmost priority. Confidentiality is primary, however in the case of a threat to self or other harm, we must report.

Medical Records: Both law and the professional standards require that we keep appropriate treatment records. You are entitled to review a copy of the records, unless the clinician believes seeing them would be emotionally damaging, in which case, we will he happy to provide them to an appropriate mental health professional of your choice. We can also prepare an appropriate summary for review. Clinicians may have charts subpoenaed in legal cases however records are usually subject to patient-clinician privilege and will only be
released with your consent or a court order. You must make your request in writing. There is a fee for these copies. Emergencies: In the event of a psychiatric emergency, such as acute thoughts of harming oneself or others, a medically dangerous reaction to a medication, or other clinical emergency such as imminent danger to self or others, please call 911 or go to your local emergency room.

Insurance Policies: You are responsible for all fees for service. We are not contracted with any insurance.It is the responsibility of the patient to fully check your benefits and coverage before your visit(s) for any possible out of network coverage. We do not guarantee any coverage and/ or Out of network reimbursement.

Disability Requests:
We understand that at times it may be difficult to continue working while dealing with a mental health crisis. State Disability is available if it is determined by our clinicians that it is the best course of action for the you, the patient. Qualifying for disability will be at the discretion of the clinician based on clinical judgment. Additional therapeutic modalities such as intensive outpatient therapy and/or multiple psychotherapy sessions will be required. This will ensure the fastest and most therapeutic path to your recovery. The fee for disability forms can be up to $100.

Payments: Unless other arrangements are approved by us in writing, the balance on your account is due and payable at the date it is requested in person. Accounts are considered past due and delinquent/subject to reporting to collections if not paid within 30 days. Any copays, office visit fees, or other costs must be paid at the time of service.
Telephone Calls & Emails: We must screen all calls to the clinicians during office hours while they are seeing patients. Calls deemed "non emergent" will be handled by the staff in the order received. If it is necessary to leave a message for the clinicians directly, calls will be returned within 24-48 hours by either the clinician or staff, as appropriate. Email will be answered by clinicians and staff directly and are confidential, but please keep in mind the limits of technology security.

Prescription Refills: Prescription refill request will be handled within 24 hours of receipt DURING OUR regular BUSINESS office HOURS: Tuesdays, Wednesdays and Fridays. This does not include holidays and clinician time off. It is your responsibility as the patient to ensure timely follow up on medication refills.Please call our office at (949) 427-5170 when requesting refills and leave a detailed message regarding the prescription. You can also send an email with your request. Certain medications that are controlled substances require monthly or every other month prescriptions and may require an office visit. Our clinicians reserve the right to deny refills or reduce quantity/doses. Patient refills may also he denied if patients have not returned for follow-ups within the time frame agreed at the previous appointment and thus a follow-up appointment must be made before refills are authorized. Furthermore, if a patient’s account is past due and payments are not received or a payment plan initiated, refills WILL NOT be granted.

Changes in Address/Phone or Insurance: Please notify us as soon as possible if you have any changes to your home or billing address, phone numbers and insurance coverage. If we do not have current information this will delay payment and possibly cause you to have unexpected expenses and delays in medication. Please also let us know if there are any concerns about the phone number we have on file. You will be asked to fill out a new information profile completely every year. WE DO NOT HAVE APPT REMINDERS AND WE DO NOT HAVE TEXT CAPACITY. YOU ARE RESPONSIBLE FOR YOUR APPT FOLLOW UP TIME AND DATE OR WILL INCURE A NO SHOW FEE IF THE APPT IS MISSED.

Legal Testimony: It is often unforeseen, but legal matters requiring the testimony of a mental health professional can and do arise. Legal testimony can often be damaging to the relationship between a patient and clinician. Because of this, we require that you employ independent forensic services should this type of evaluation be required. If for any reason, we are subpoenaed on your behalf and required to testify or appear in court, you will be responsible for our court fees, which our office can provide upon request.

Psychotherapy: Psychotherapy may have benefits such as significant reduction in stress, improved social relationships, resolution of specific problems, and clearer understanding of yourself, your values, and your goals. For therapy to be most successful, you will have to be able to talk openly and honestly, address any difficulties that arise, and put forth active effort outside your sessions. Therapists have expertise in several areas of therapy and will collaborate with clients to create an individualized plan. Some therapy is brief and some requires a longer duration to address symptoms and treatment goals. If you have any questions or uncertainties, please discuss them with your therapist.

Pharmacology /Medications: Medications are often used as adjuncts to psychotherapy. If you are seeing clinicians at Inner Balance Psychiatry & Wellness, Inc. for medication management, we will work together to find the optimal combination of medication (if warranted) and therapy that help to fulfill your personal goals. If a medication is indicated, we will discuss with you the reason for the medication, the likelihood of improving with and without medication, and any reasonable alternative treatments. Further, you will understand the type(s) of medication being recommended; dosage and frequency and any possible side effects. As many conditions have an underlying biological basis, medications can be an important component of treating certain illnesses. A common concern in psychiatry of prescribers seeing patients for quick visits, focusing almost entirely on medications, over-prescribing, not being open to working with therapists, and not educating patients about their condition or needs is not what occurs in our practice. Medications are used in conjunction with therapy as the catalyst for growth, with a focus on prescribing only when needed, reducing the use of substances that can increase addiction. A pharmacological plan specific to the unique needs and symptoms of the individual with be obtained.

Laboratory Tests & Procedures: As part of your treatment plan, we may recommend certain lab tests/blood work to be ordered to assist in diagnosis and rule out medical causes to symptoms. Our practice focus is on comprehensive care and as such, genetic or Neurotransmitter testing may be utilized. Certain medications also require routine and periodic blood work. Please make sure to discuss any physical symptoms, past medical history, etc. that may be important in your current situation. If labs are ordered, it is your responsibility to make sure that lab services are an included benefit in your insurance.ALL FUNCTIONAL MEDICINE TESTING KITS ARE NONREFUNDABLE.

Referrals/Authorizations: If your insurance requires a referral or pre authorization you are responsible for obtaining it. Failure to do so may result in payment denials from your insurance. Occasionally our clinicians will refer you to another specialist. Recommendations are based on their experience with the specialist but the specialist may/may not be an in-network provider with your insurance carrier. You will need to contact the office and/or your insurance to determine if that provider is covered. We reserve the right to charge for prior authorizations that may be necessary for medications based on your insurance plan coverage.

Patient-Provider Arbitration Agreement: Lawsuits are something that no one anticipates and everyone hopes to avoid. The method of resolving disputes by arbitration is one of the fairest systems for both patients and psychotherapists. By signing this office policy contract, you are agreeing that all disputes arising out of or in relation to this agreement to provide services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement with Inner Balance Psychiatry & Wellness, Inc. and patient(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Orange County, CA, in accordance with the rules of the American Arbitration Association which is in effect at the time the demand for arbitration is filed. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California court system. You may call witnesses and present evidence. Each party selects an arbitrator who then selects a third neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and psychotherapists. Our goal of course is to provide care in such a way to avoid any such disputes. Most problems begin with communication and thus if you have any questions or concerns about our care, please discuss with our office/clinician.

Children & Pets: Children are welcome but for their safety and the courtesy of other patients we must ask that you keep your children with you at ALL times while in our office. Pets are not allowed in the office building, except animals that are registered service/therapy animals.

Cell Phones & Smoking / E-Cigarettes: Please refrain from talking on your cell phone and smoking/using electronic cigarettes while in the office or waiting area. This is distracting to others around you and also to the environment that we hope to create within our office. Please be mindful that there are several professional businesses within this office building and thus respect their need for a quiet environment.

Grievance Policy: Communication is an essential element of your healthcare and interpersonal relationships. If at any time you have concerns, please discuss with either your therapist/clinician and/or our office manager. If resolve has still not been achieved, you have the right to request a meeting with the owner to discuss your concern.

By signing below, I acknowledge that I have read the above office policies and procedures and am consenting to treatment with Inner Balance Psychiatry & Wellness, Inc. and agree to abide by the terms during our professional relationship. This is an agreement between Inner Balance Psychiatry & Wellness and the Patient/Client named on this form.

Patient / Patient Representative / Guardian Signature


Many offices will overbook appointments to augment the possibilities of no show visits. Our practice believes in providing appropriate time to evaluate and manage our patient’s needs without having to rush through visits. We are known for providing more than just medications and quick visits. Therefor, it is expected that you will pay for the visit you scheduled at the time of service. It will be required that you provide 24 BUSINESS HOURS PER OUR BUSINESS HOURS AS STATED ABOVE notice to cancel or reschedule your appointment. This will allow another patient to be seen instead of having wait lists or limited time and availability. WE DO NOT HAVE APPT REMINDERS AND WE DO NOT HAVE TEXT CAPACITY. YOU ARE RESPONSIBLE FOR YOUR APPT FOLLOW UP TIME AND DATE OR WILL INCURE A NO SHOW FEE IF THE APPT IS MISSED. If you fail to provide 24 business hours, you will be charged for the FULL COST OF THE VISIT. Business hours are as stated above. Fees may range from $125-$495 depending on the visit scheduled. Payment will be made by credit card on file, as noted below. If the credit card on file is not valid and payment cannot be made then it will be required to pay any balance and future visit cost prior to scheduling your next appointment.


It is our office policy to collect and maintain a valid credit card on file. We will keep this information in a HIPPA compliant manner and will only be used in the event the patient has violated the above no show late cancellation policy. All other payment for other services such as disability will be required at the time of service. It is the responsibility of the patient to update our office with a current and valid credit card.

I have read, understand and agree to the above policies for Inner Balance Psychiatry
& Wellness.

Patient / Patient Representative / Guardian Signature


I have read and understand the above mentioned policies for Inner Balance Psychiatry & Wellness. I authorize Inner Balance Psychiatry & Wellness to charge my credit card for the
reasons stated above. I am aware that my card will be entered manually and no signature will be required and I am consenting to this per the parameters above. I will not dispute charges for visits and or services that have been received or visits I did not provide 24 business hours notice to cancel or reschedule.

Card Holder Signature


OVERVIEW OF THERAPY WITH KIDS/TEENS:Confidentiality with working with kids/teens can be difficult for parents/guardians to understand. Children/teens won't feel safe to open up in unless they can be assured that what they say will be kept private. On the other hand, as a parent, you have a right to know how your child is progressing. In general, we will tell children that while we will be speaking with their parents from time to time, we won't share specifics of our work unless the child and clinician(s) have agreed beforehand. The exception is when information is obtained that falls under mandated reporter status (child/dependent/elder abuse) and/or knowledge that the child is suicidal or involved in any dangerous activities. In these cases, parents and the appropriate agencies (for abuse) will be notified. When working with kids/teens, the clinician, child and family are partners in their
growth, but the therapist/clinician must serve as the guide while in treatment. The frequency of parent meetings depends on the individual and is done periodically or as issues arise. In between sessions, you are welcome to email any concerns or updates to our practice with respect to the time it takes outside of the office to read these concerns/requests. Please use this mode of communication, including phone contact, to convey only the most important information and of course for any urgent issues.

psychiatric consultation can be an emotional and overwhelming process for parents. There is much to navigate when deciding whether medications are right for your child. Our practice is very conservative with medications and will discuss all alternative treatments, the role of therapy, diet/exercise/sleep needs, medical issues, etc. as part of a treatment plan. However, for many, medications are an essential element to treating symptoms and illnesses in mental health, just as in any other area of medicine. There can be a great deal of stigma surrounding mental health, as well as inaccurate information in the media. One area surrounds the accusations of suicide risk in kids/teens on antidepressants, which is based on research that is not methodically sound. In addition, another challenge is that a majority of the medications needed to target certain biochemical pathways and areas of the brain are not FDA approved, but are standard of care when practicing evidence-based medicine and psychopharmacology. You can be assured that you will work closely with our clinician and collaborate on a plan that is best for your family.

We/I, the undersigned parent(s) and/or guardian(s) of minor child, give you full authority to proceed with a clinical evaluation and treatment as your judgment indicates. This consent is given by we/us as parent/or guardian(s) of said child. We/I have legal power to consent to medical, psychological, and mental health assessment and treatment of said minor child.

Guardian Signatures


Inner Balance Psychiatry & Wellness
23421 South Pointe Drive Suite 275
Laguna Hills , CA 92653
Office 949-427-5170
fax 949-940-1160

I understand that under the Health insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand by signing this form that this information can and will be used to (1) conduct, plan and direct my treatment and follow up care among multiple healthcare providers that may be involved in that treatment directly or indirectly (2) obtain payment from designated third party payers (3) conduct normal health care operations such as quality assessments or evaluations and physician/ clinician certifications.

I have been informed of the Notice of Privacy Practices containing a more detailed description of the uses and disclosures of my health information ( available on the website at or in the office in print form). I acknowledge that I have read, reviewed, studied and understand such Privacy Practices prior to signing this consent. I understand that I may request in writing that this Practice restrict how my private information is used or disclosed to carry out treatment, payment to other health care operations.

I understand that the Practice above has the right to change its Notice of Privacy Practices from time to time, and that I may obtain a revised copy by contacting the office. I also understand the Practice is not required to agree to my requested restrictions, but if the Practice does agree, then it is abound to abide by such restrictions and such future disclosures will cease. I understand I may revoke this consent in writing at any time, except to the extent that the Practice has taken action relying on this consent.

I understand the Practice may condition receipt of treatment upon the execution of this consent.

Signature (Patient /Guardian/Legal Rep)