Advanced Behavioral Health Counseling

Specializing in Group, Individual, Coaching and Marital Therapy

New Patient Form

Advanced Behavioral Health

Sylvia Ybarra, M.A., M.F.T.

29645 Rancho California Rd. #238 

Temecula California 92591 United States

951 852-1870

 

Welcome

I am happy to have you as a client and will do everything in my professional capacity to provide you with the best possible mental health care.

*Sex
Male
Female
Responsible Person:  (Note: If this information is same as patient, write ďsame as aboveĒ) Insurance Information:

Consent for Treatment:

I consent to assessment, treatment, and/or diagnostic procedures for myself or for my family member.  I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement.  I authorize the release and exchange of information between my therapist and the referral source and other co-treating providers for the purpose of treatment, payment, and Health Care Operations.  I also authorize the release of information to my health plan for claims or other health plan purposes.

*
I Agree

Please rate the severity of the following symptoms over the last month according to the following rating scale:               

0-No difficulty

1-Mild

2-Moderate

3-Severe