211 S. Primrose Ave.
Monrovia CA 91016
(626) 359-4330
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  • 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 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
 


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