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Book a telehealth appointment with a Behavioral Health provider!

This request form is for non-urgent appointments only. For emergencies, please call 911 or visit your nearest emergency department.

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Patient Information

Gender at birth*MaleFemalePrefer not to say

CalOptima Health Member ID*

Date of birth*

Emergency Contact Name*

Phone Number *

Emergency Contact Relationship

Name of person completing form and relationship to patient*

Reason for appointment*

Current Medicines and Dosage *

List any medical allergies*

Primary Care Provider (Name, Phone, Address)

Do you often see a Behavioral Health provider for care? If yes, please share where: YesNo

Appointment type *First AppointmentFollow-up Appointment

Is patient a minor ?*YesNoAre you dealing with any legal problems right now? Has a court judge, parole officer or Child Protective Services (CPS) told you to get mental health care or assessment?*YesNoPlease choose if you have ever had or are currently experiencing any of the following:
(check one or all that applies)Have you had thoughts of harming yourself?*PastCurrentlyNeverHave you had thoughts of harming others?*PastCurrentlyNeverHave you struggled with alcohol abuse?*PastCurrentlyNeverHave you struggled with substance abuse?*PastCurrentlyNever

Preferred Pharmacy

Name

Phone No

Address

City

State

Zip

ConsentI agree to the TeleMed2U Terms & Conditions, Telehealth Consent, Privacy Policy and Notice of Privacy Practices, and understand all of these can be accessed at any time on telemed2u.com.I have read and give my permission for the Release of Information

Disclaimer: Self-paying patients have to pay their balance prior to their appointment.

Thank you for submitting this form, a team member will give you a phone call within 1 business day to schedule your appointment.

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Contact Us

Phone:
(562) 268-0955

Fax:
(562) 605-0088

Email:
caloptimabh@telemed2u.com

© 2021 TeleMed2U. All Rights Reserved. • Terms • Privacy Policy • NOPP • Telehealth Consent

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If you are actively in crisis, please call or text 988 for the Suicide & Crisis Lifeline. TeleMed2U does not provide emergency or crisis services. For additional immediate support, you can also contact the Revive support at 800-327-2251. By continuing, you acknowledge and consent that you understand TeleMed2U is not a crisis response provider.

TeleMed2U does not provide specialized treatment for Alcohol Use Disorder.

Our clinicians can support underlying behavioral health needs, but we are unable to treat, manage, or prescribe for alcohol misuse. For help with alcohol use, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Alcohol Use Disorder.

TeleMed2U does not provide specialized treatment for Substance Use Disorders.

Our clinicians can support underlying behavioral health needs, but we cannot treat, manage, or prescribe for substance use. For support, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Substance Use Disorders.