Account Profile

We understand that you expect the highest level of security when it comes to protecting your personal information.

Beachside Adult and Family Therapy Inc uses various authentication technologies and security controls. The communication between your computer and our web servers is secured with Digital Certificates. This technology ensures the privacy and integrity of your data and authenticates the identity of our servers. We encrypt your personal information with 256-bit encryption keys and verify that your encrypted information is not tampered with.

Please choose a username and password for Beachside's online portal. Our online portal login button is located on the top menu of https://Beachside-Therapy.com.

User Name:

Password:

Patient's Information

Reason for Visit:

*Please provide a brief description of the problems for which the patient is seeking therapy

Patient's Legal First Name:

Patient's Legal Last Name:

Patient's Preferred Name

**If different than legal name

Date of Birth

Social Security Number

Street Address, City, State, Zip

City, State, Zip

Add another phone

Employer Name

Email Address

Account Responsible Information

Who is legally responsible for the person entered above?

Self Enter a Parent or Other Responsible Party

First Name

Last Name

Date of Birth

Street Address

City, State, Zip

Add another phone

Email Address

Medical Insurance Information

Do you have insurance coverage?

Yes, I have insurance coverage

**Please list all carriers

No, I am Self Pay

Add another insurance carrier

Payment Information

A card on file is required regardless of insurance coverage. Co-payments or Deductible amounts plus a 3% transaction fee will be processed after confirmation of charges, typically one business day after the date of service, unless your insurance is expected to cover the full cost of the session. If there are unusual charges or fees, an account statement will be emailed one business day before your payment is processed.

Full Name on Account

16-digit Debit or Card Account Number

Card CVV Code

Card Expiration Date

**After it is saved into your electronic record, all card-related information is hidden. Payment card numbers cannot be retrieved by staff at Beachside Therapy, technical support, or any of our contracted partners. To update your saved payment method or if you have any questions or concerns, please call the billing office at 805-620-0346, Wednesday to Sunday from 8am - 2pm.

Who should we contact in case of emergency?

Name

Add another phone

Description / Name

By checking the box below, I acknowledge that I have reviewed Beachside Therapy's Privacy Policy (Click here to view in a new tab) in its entirety and that I have the right to ask questions regarding the information contained therein prior to initiating treatment:

I have read the Privacy Statement

Your information will be encrypted.