211 S. Primrose Ave.
Monrovia CA 91016
(626) 359-4330
  • If this page automatically refreshes, you will have to start over. (This helps protect your information.)
  • Do not use the browser's back or refresh button.
  • The online intake process may take up to 5 minutes to complete. Please make certain you have enough time to complete this in 1 session.
  1. Please download the forms.
  2. Click on the 'Step 1' tab and start the online intake process.

Download Forms

If you are unable to download a form please switch browsers...IE and Chrome work; there is a known bug in Firefox.
Agreement for Telehealth & Instructions
Consent for Audio/Video Recording
Consent For Services
Consent To Release Information
Consent To Treat A Minor
Minor Consent For Treatment

Step 1

Are you completing this online intake as (select one):
An Adult Patient
A Minor Patient (under 18 as of today)
The Parent/Guardian of a Minor
 

Copyright © 2020 The Place Within All rights reserved. Reproduction in whole or in part in any form or medium without express written permission of The Place Within is prohibited. Web site design by Everet Milner. Privacy/HIPAA Compliance Information