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Client / Patient Full Name*

First NameLast Name
Client / Patient Phone*
Please enter a valid phone number.
Client / Patient Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number
Enter a valid SSN
CIN*
Enter a valid CIN
MRN (Medical Record No.*For Kaiser clients only
Sex?*

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Other
Do you (client) have health insurance?*
If Yes, what insurance do you have?
Support Services Needed*

Mental wellness supportBehavioral supportLife & wellness coachingMovement therapyNutritional counselingMindfulness based stress reduction (MBSR)All of the aboveOther
Medical Issues/Health History*

AsthmaDiabetesDepressionAnxietyDrug/Alcohol DependencyHigh Blood PressureThyroid DiseasesAutoimmune DiseaseChronic PainGynecologic disorderOther
Aggression/Criminal History*
Explain any Aggression issue/criminal history that may impact client participation in our services
Preferred Time Slots for Appointment
Check all that apply:

Morning (8:00 am - 12:00 pm)Afternoon (12:00 pm - 4:00 pm)Evening (4:00 pm - 8:00 pm)
Preferred Appointment Type
Check all that apply:

In-Person - Newport Beach Clinic (1441 Superior Ave, STE A)Virtual/TelehealthBoth
Additional Notes
Please provide any additional notes regarding your availability
Disclaimer:

Please note that Poppy Life Care service does not provide crisis assistance or emergency intervention for individuals in immediate distress. If you are experiencing a crisis, having thoughts of self-harm, or are in need of immediate support, please contact a crisis hotline or seek assistance from local emergency services. Your safety and well-being are of utmost importance. Please reach out to the following resources for immediate help:
- National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
- Crisis Text Line: Text HOME to 741741
- Emergency Services: Call 911 or visit the nearest emergency room
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Book a Free Consultation

Preferred Time Slots for Appointment

Preferred Appointment Type

Additional Notes