Name *

First Name

Last Name

Phone

(###)

###

####

I am Seeking Services for:

Individual Therapy

Additional Services

Preferred Form of Communication

Phone Call

Text

E-mail

Acknowledgement *

Please note that electronic communication or messaging via this web portal is not encrypted. There is a possibility that the information you include in your submission can be intercepted and read by parties other than the intended recipient. To protect your privacy, please do not include personal medical information in your submission. Alternatively, you may call 714-650-8650. By including personal medical information in this form and submitting it via this web portal, you acknowledge and accept the above risks of communicating such information through an unencrypted and unsecured electronic method. By clicking "Yes, I understand and agree to the terms of use" and submitting this form, you agree to hold Well-Being Heritage Therapeutic Services, its respective officials, directors, employees, members, and agents harmless from and against any and all damages, claims, obligations, and liabilities arising out of any unauthorized use of, disclosure of, or access to your personal health information included and submitted via this web portal.

Yes, I understand and agree to the terms of use.