Intake and Admission Forms

Contact Us:

Name:
Email:
Phone:
Message:

The following PDF document is an Authorization for Credit Card Payment form for Cornerstone of Southern California

Authorization for Credit Card Payment Form

There are three ways in which you can fill out and return the following document:

A). Option 1:

  1. Please ‘PRINT OUT’ the form.
  2. Please ‘FILL OUT USING BLACK INK’.
  3. Scan the form back to your computer. 
  4. Attach form to an email addressed to contact_us@cornerstonesocal.com

B). Option 2:

  1. Please ‘PRINT OUT’ the form 
  2. Please ‘FILL OUT USING BLACK INK’ 
  3. Fax to us at 1-714-541-3320 or mail to below address.

C). Option 3:

  1. Please ‘PRINT OUT’ the form
  2. Please ‘FILL OUT USING BLACK INK’  
  3. Please bring the form with you upon admission to the Cornerstone Program.

Additional Informational Forms

Additional Information:

  • The mailing address for all Cornerstone forms is:
    1950 E 17th St Suite 150
    Santa Ana, CA 92705
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