Client Demographics
Personal, contact, insurance, housing, cultural, legal, and accommodation information.
Choose an inquiry type to begin. The form adapts to the information needed for insurance verification or a court and justice referral.
Choose your secure next step
Complete new-client paperwork securely
Complete each secure form in a new tab. Your answers and uploaded identification go directly to Heart 2 Heart through Hush Secure Forms and are not stored on this portal.
Please do not email identification or completed paperwork. Use only the secure buttons below. Staff may contact you if additional signatures or documents are needed. Date fields, including birthdate, today’s date, and appointment date, should be completed with the calendar controls inside the secure form.
DHCS License/Certification No. 360171AP
Heart 2 Heart Behavioral Health — 24230 Barton Rd, Suite A, Loma Linda, CA 92354
Personal, contact, insurance, housing, cultural, legal, and accommodation information.
Review program terms, rights, responsibilities, rules, refund policy, and treatment consent. Complete and sign the secure digital version.
Consent for remote telemedicine and teletherapy care, including benefits and possible risks.
Authorize Heart 2 Heart to release or obtain records for care coordination, legal, or personal purposes.
Authorize or decline use of your image, voice, or likeness. Your services are not affected by your choice.
Upload clear images of the front and back of a government-issued photo ID through encrypted Hush Secure Forms.
A state-required rights notice is needed for admissions. The uploaded PDF names another medical practice, so it is not linked for client signatures. Upload a Heart 2 Heart-branded version before publishing this form.
Comprehensive support beyond treatment
Programs for adults 18+ led with structure, compassion, and respect.