Fusion Care Group | SimplePractice

Fusion Care Group Send Message

Your info

First name

Last name

Phone

Date of birth

Sex at birth

For insurance verification

State

Select the state you live in

Parent/Guardian Email Address (if client is a minor)

Parent/Guardian Phone Number (if client is minor)

Reason for care

What is the reason for seeking care?

Anxiety ADD/ ADHD Stress or Life Transitions Depression Grief Relationship issues Substance use Trauma Medication Manangement Parenting Other

Billing & Payment

Payment method

How do you plan to pay?

Who is your primary insurance company?

Insurance card upload

Upload a photo of your insurance card

Insurance Member ID number

Secondary Insurance company (if any applies)

Secondary Insurance Member ID (if applicable)

Legal name that matches your insurance card

Client Preferences

Preferred appointment times (mark all that apply)

Preferred day of week and times for weekly ongoing appointments

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays 7-11 AM 11-2 PM 2-6 PM 6-10 PM All Day

Telehealth or In person services preferred

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

In Person Location (mark all that apply)

Which one of our locations are you seeking In-person services at?

La Mesa Santee Alpine Oceanside Rancho San Diego San Luis Obispo Chula Vista Temecula Vista Laguna Hills Poway Riverside Palm Springs Mesa, Arizona Phoenix, Arizona Sand Point, Idaho Mission Valley Harrison, NY

May we text you for faster initial scheduling?

yes no

Clinician Preference

Female Male No Preference

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.