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.

Reason for Visit

Please provide a brief description of why the patient is seeking therapy:

*Space for additional details will be available on our Medical History form.

Account Responsible Information

Who is legally responsible for the patient?

Self Enter a Parent or other Responsible Party

First Name

Last Name

Date of Birth

Add another phone

Street Address

City, State

Zip Code

Email Address

Medical Insurance Information

Does the patient have insurance coverage?

Yes, I have insurance coverage

**Please list ALL insurance plans

No, I am Self Pay

ADD INSURANCE

** Failure to provide all insurance information may cause delays or denial of insurance payment. Provide all secondary and tertiary coverage above even if it is believed other plans will not be billed. Financial responsibility for unpaid services rests with the patient or responsible party.

Patient's Information

Patient Legal First Name:

Patient Legal Last Name:

Patient Preferred Name

** ONLY IF DIFFERENT THAN LEGAL NAME **

Patient's Street Address

City, State

Zip Code

Add another phone

Patient Date of Birth

Email Address

Employer Name

Occupation

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

Numbers 1-4

Numbers 5-8

Numbers 9-12

Number 13-16

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, Tuesday to Friday from 9am - 4pm.

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.