Outpatient Services - Fremont Hospital
JoAnne Lucich, Ph.D. - Director of Outpatient Services
Intake Coordinator
(510) 574-4851
info@outpatientservices-fremonthospital.com


         
Accredited by The Joint Commission
Helpful Forms

If you're a new patient, client, please complete the following forms and bring them with you on your first day with us.

  • Patient Intake Form
  • Registration Information Form

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form

 Patient Intake Form  
                  Patient Intake Form  
Authorization to Disclose Information Form  

Note: To download Adobe Acrobat Reader for free, click here.