Accessibility View Close toolbar

Intake Forms

By completing the form below, you agree to the following terms.

I certify that I (and/or my dependant(s)) have insurance coverage with the above carrier and I understand that I am financially responsible for
all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named provider
may use my health care information and may disclose such information to the above named insurance company and their agents for the
purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my
current treatment plan is completed.


I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any
necessary information, including medical information for this or any related claim, to the above-named insurance carrier(s). I permit a copy of
this authorization to be used in place of the original. This authorization may be revoked in writing either by me or the above-named carrier at
any time. I certify that I represent only myself or individual(s) for whom I am guardian and am not here on behalf of a third party. I authorize
treatment by any or all providers and professional staff affiliated with Rockman Family Counseling.


Payments: We accept cash, checks or any major credit card. Fee is $250. an hour, unless otherwise specified and is customary for
services to be paid when services are rendered. Insurance: As a courtesy we submit all Insurance claims to your carrier. Please note unless agreed upon otherwise, any payment made by your insurance company in most cases will be paid directly to the Subscriber. The exception is Medicare where Rockman Family Counseling accepts assignment and Medicare’s payment.


A Credit card may be kept on file for payment. Or if you prefer you may provide a credit card during your first visit with Dr
Rockman. I Authorize Rockman Family Counseling to charge my credit card for any fees not paid at time & place of service. 

Contact Dr. Rockman

You can text Dr. Rockman for an immediate response (949) 230-9602

Location

Dr. Rockman Has Two Orange County Locations

Availability

Please Text Dr. Rockman ANYTIME at (949) 230-9602 for an Immediate Response.

Standard Appointment Hours

Monday:

11:00 am-8:00 pm

Tuesday:

11:00 am-8:00 pm

Wednesday:

11:00 am-8:00 pm

Thursday:

11:00 am-8:00 pm

Friday:

11:00 am-8:00 pm

Saturday:

12:00 pm-6:00 pm

Sunday:

12:00 pm-6:00 pm