260 Maple Court, Suite 228, Ventura, CA[email protected] 805-791-9700
Forms
Please use the following forms for your first appointment with your VCC Clinician.
If you’re an adult client, please click on the following forms to download. Fill them out and bring them in to your first appointment, or email them to your therapist.
If you’re the parent or guardian signing on behalf of a child or adolescent client, please click on the following forms to download. Fill them out and bring them in to your child’s first appointment.
Forms
Please use the following forms for your first appointment with your VCC Clinician.
If you’re an adult client, please click on the following forms to download. Fill them out and bring them in to your first appointment, or email them to your therapist.
Adult Intake Form
VCC Consent to Treatment
For Out of Pocket Pay – Fee Agreement and Cancellation Policy
For Gold Coast / Medical Insurance – Fee Agreement and Cancellation Policy
For Cigna / Evernorth Health Insurance – Fee Agreement and Cancellation Policy
Telemedicine Consent Form
Consent to Release Information (to allow us to speak to your doctor, psychiatrist, etc.)
Debit/Credit Card Authorization Form
If you’re the parent or guardian signing on behalf of a child or adolescent client, please click on the following forms to download. Fill them out and bring them in to your child’s first appointment.
Child Adolescent Consent to Treat
Child Adolescent Intake
Fee Agreement and Cancellation Policy
Debit/Credit Card Authorization Form
Los siguientes formularios están en español. Por favor, llénelos y tráigalos a su primera cita.
Spanish Consent to Treat – Consentimiento al Tratamiento
Spanish Fee Agreement and Cancellation Policy – Acuerdo Financiero y Politica de Cancelacion
Spanish Adult Intake Form – Formulario de Entrada
Contact
260 Maple Court, Suite 228
Ventura, CA 93003
Call:
confidential
Email:
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