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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.

Please fill in the form below.

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Spanish

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)Thoughts of harming others*PastPresentNoThoughts of Harming Yourself?*PastPresentNoAlcohol abuse*PastPresentNoSubstance abuse*PastPresentNo

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