"Quality, Confidentiality & Convenience"

Please download the forms below before coming into the office.  This will save you time and allow Dr. Russell to start with you promptly at your appointment time.  

Prior to coming into the office, fax your (1) Intake Form, (2) Insurance Benefits Worksheet and (3) a copy of your insurance card (front and back) to 562-799-3355.  

You may  bring the other forms with you on your first visit.  If you are unable to download and fax in these forms, please let us know and arrive twenty  minutes early for your paperwork.  

You will be required to pay for your first visit in full if you do not have current insurance benefits pre-determined and your care pre-authorized (if necessary).

INITIAL OFFICE VISIT FORMS (download all and bring them on first visit)

    1. Initial Intake Form

    2. Insurance Benefits Worksheet   
        (You only need to fill out the following form if you wish to use your insurance benefits to help pay for services.  Bloch  Medial Clinic and Southern California Mental Health Associates patients do not need to fill this out.)

    3. Treatment Goals

    4. Self-Assessment

    5. Confidentiality Agreement 

    6. Appointment Policies

    7. Financial Policies

    8. Symptom Monitoring Checklist

    9. HIPPA form

You will need Adobe^®  Reader^®  to download these forms.  If you do not have it, you may download it free by pressing here.

You will need to bring the above forms with you to the intial visit.  Additional forms may be required by your insurance company, so plan to arrive early in case this is neccessary. 

Remember to call if you cannot keep your scheduled appointment.

We look forward to seeing you.

You may click here to get a MapQuest map to the office.