Request an appointment for psychotherapy.

Thank you for choosing Sean C. Rathan, MFT for your behavioral health

provider.

Please fill in the information below to request an appointment

for psychotherapy services. I am currently accepting appointments for

adults, ages 20 to 65 years old.

For faster appointments, please call your insurance to verify benefits

for behavioral health coverage, copays, deductibles, and co-insurance.

See the back of your card for phone numbers for "Member Services" or

"Provider Services."

Therapist Contact Information

Sean C. Rathan, MFT

MFC35350

10061 Talbert Avenue, #200A

Fountain Valley, CA 92708

714-865-2157

Patient Information

First Name *

Last Name *

Date of Birth (MM/DD/YYYY)
Needed to verify benefits

Phone Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Marital Status *

Is this your first visit to our offices? *

Yes

No

Day and Time of Preferred Appointment

Choose Preferred Day *

Notes:

Appointment Information

Preferred Provider

Sean C. Rathan, MFT (Population: Ages 20 to 65, Males/Females, Single/Divorced/Couples)

Referred by: *

Please describe the reason for this visit *

Insurance Information

Member ID# (include letters) *

Provider Services (Mental Health) Contact Phone # *

Authorization #

Subscriber Name *

Subscriber Date of Birth *

Subscriber Relationship to the Patient *

Employer *

Occupation *

*

Attachment option for copy of your Insurance Card or Benefits