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Therapist Contact Information
Clear Reflections Psychological Services
Christina Johnson MFT #43740
16897 Algonquin Street, Ste. L
Huntington Beach, Ca 92649
714-345-1236
Patient Information
First Name
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Last Name
*
Birth Date (MM/DD/YYYY)
Needed to verify benefits.
*
Street Address
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Address Line 2
*
City
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State
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Zip Code
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Phone Number
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Email Address
*
Marital Status
*
Appointment Information
Choose Preferred Day & Times
Monday
Tuesday
Wednesday
Thursday
Friday
Referred by:
Therapist Requested
Please describe the reason for this visit
*
1st & Last Subscriber Name
*
ID#
*
Group#
*
Pre Authorization#
Insurance Carrier
*
Insurance Phone Number
Relationship to Patient & their date of birth
*
you must have at least one item
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