Mary E. Rodela, MS, LMFT

(562) 652 – 9317

Please bring forms to your first appointment,

if you have any questions, they can be addressed at that time.

Forms are in two formats:

(Print Only) which you print out and complete

or (Fill-In & Print) which you complete online

and then print out.

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Patient Information (Print Only)

Patient Information (Fill-In & Print)

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Informacion del Paciente – Espanol

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Initial Questionaire Form – Adults or Couples (Print Only)

Initial Questionaire Form – Adults or Couples (Fill-In & Print)

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Initial Questionaire Form – Child or Adolescent (Print Only)

Initial Questionaire Form – Child or Adolescent (Fill-In & Print)

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Behaviorial_Symptoms Checklist (Print Only)

Behaviorial_Symptoms Checklist (Fill-In & Print)

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Authorization To Treat a Minor

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Authorization to Exchange Confidential Info (Print Only)

Authorization to Exchange Confidential Info (Fill-In & Print)

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Informed Consent – Telemed_Eng

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Credit Card Authorization (Fill-In & Print)

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Notice of Privacy Practices_Patients Copy