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 *

Last Name *

Birth Date (MM/DD/YYYY) Needed to verify benefits. *

Street Address *

Address Line 2 *

City *

State *

Zip Code *

Phone Number *

Email Address *

Marital Status *

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