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Psychological Behavioral Health Inc.
Email *
What is the member's preferred language? *
Insured person's phone number? *
First name of the person starting treatment? *
Last name of the person starting treatment? *
Date of birth of person starting treatment? *
What is the age of the person who will be starting treatment? *
The age of the person starting treatment is 6 to 17 years of age? *
First and last name of the person completing this form? *
If a minor, what is the insured person's date of birth? *
Preferred days and times to attend services? *
Do you prefer a male or female clinician for therapy? *
Telehealth or in-person or no preference? *
Services *
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Can you send and receive text messages on your phone? *
Do you consent to send and receive an email?
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What is the name of your primary insurance carrier? *
Insurance ID? *
What is your secondary insurance name and ID, if any? (or type none) *
What is your insurance copayment? *
Insured person home address, city, zip code, and state? *
I would like to discuss medications to treat the following possible conditions: *
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How did you hear about Psychological Behavioral Health Inc. *
Did one of the clinicians already agree to offer you services? If yes, please provide the name: *
In a few sentences, please let us know the reasons you are seeking services? We use this information to match you with a therapist. *
Additional information? *
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