New Patient Paperwork

Please fill out our intake form and send it back to us. The completed form must be received 24 hours before your appointment in order to be confirmed.

Download the form here: New Patient Paperwork
Open using Adobe Acrobat Reader. You can download the application here: https://acrobat.adobe.com/us/en/acrobat/pdf-reader.html
Fill out the form and click save. You can also print a copy for your records. If you are having problems adding your digital signature, please use the instructions below.
Send the form via email attachment to this address: info@southbaycounselinglcsw.com

Digital Signature

When you need to add your digital signature to the signature field on the form for the first time, use the following instructions:

Click “Configure Digital ID ”
Click “Create a new Digital ID”
Save to File
Fill out information and click “Continue”
Select place to save digital signature and add password
Select signature. Insert password. Click “Sign.”
Save document. You can now use this digital signature for the rest of the signature fields.

Notice to clients and prospective clients:
Under the law, health care providers need to give clients who don’t have
insurance or who are not using insurance an estimate of the expected charges for
medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of
any non-emergency healthcare services, including psychotherapy services.
You can ask your health care provider, and any other provider you choose, for a
Good Faith Estimate before you schedule a service, or at any time during
treatment.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you
can dispute the bill. Make sure to save a copy or picture of your Good Faith
Estimate.
For questions or more information about your right to a Good Faith Estimate, or
how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.