Belmont Psychological Services
  • HOME
  • About Us
  • Who we treat
    • Help for Children and Teens
    • Help for Couples & Families
    • Help for Defiant Teens
    • Help for Older Adults
  • Specialties
    • Anxiety and Phobias
    • Obsessive Compulsive Disorder
    • Teen Support Group
    • Parenting Skills Training
    • Substance Use Disorders
  • Therapists
    • Dr. Katy Manetta
    • Dr. Michelle Beakey
    • Dr. Jade Starleaf
    • Ms. Jaime Dunham
    • Mrs. Nancy Cano
    • Ms. Bethany Mendoza
  • Covid 19
  • BPS BLOG
  • Social Anxiety
Private Pay Patient Forms​
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Please choose the appropriate category below and follow the links to print and complete the paperwork for your scheduled intake. When you have finished your paperwork, please send it to our office by fax at 562-799-6733 or by mail at the address listed at the bottom of this page.
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Forms for Adults

Teletherapy Consent Form (All Others)

Patient Information 

Consent for Treatment 

Electronic Communication Policy 
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HIPAA Acknowledgement and Notice Form


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Forms for Children and Adolescents

Patient Information

Consent for Treatment

Child Therapy Contract

Adolescent Consent Form (Only for patients between the ages of 13-17)

Electronic Communication Policy
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​HIPAA Acknowledgement and Notice Form
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Belmont Psychological Services

6615 E. Pacific Coast Highway Suite 255 
​Long Beach, California 90803
Ph: 
562-799-6700 Fax: 562-799-6733
Email: belmontshorepsych@gmail.com
© Copyright 2016-2020  ​
​Belmont Psychological Services
 ​
​All rights reserved
  • HOME
  • About Us
  • Who we treat
    • Help for Children and Teens
    • Help for Couples & Families
    • Help for Defiant Teens
    • Help for Older Adults
  • Specialties
    • Anxiety and Phobias
    • Obsessive Compulsive Disorder
    • Teen Support Group
    • Parenting Skills Training
    • Substance Use Disorders
  • Therapists
    • Dr. Katy Manetta
    • Dr. Michelle Beakey
    • Dr. Jade Starleaf
    • Ms. Jaime Dunham
    • Mrs. Nancy Cano
    • Ms. Bethany Mendoza
  • Covid 19
  • BPS BLOG
  • Social Anxiety