Please call 805-246-7104 after you complete this form. The scheduler will then review your information. The scheduler will then contact you and direct you to "" to select "clinicians" and select an "appointment". Please make sure you touch base with the scheduler first before you schedule an appointment.
Psychological Behavioral Health Inc.
Email address *
Preferred days and times to attend services? *
Do you prefer a male or female clinician for therapy? *
Insured person's phone number? *
Services (Dr. Bimbela is only offering medication services) *
Can you send and receive text messages on your phone? *
What is the name of your insurance carrier? *
Insurance ID? *
What is your insurance copayment? *
Insured person home address, city, zip code, and state? *
Parent date of birth (insured)? *
First and last name of the person completing this form (Adult/Guardian)? *
First and last name of the person starting treatment (Child-Adolescent)? *
Date of birth of person starting treatment? *
The age of the person starting treatment is 6 to 17 years of age? *
What is the age of the person who will be starting treatment? *
What is the reason(s) for starting treatment? *
I would like to discuss medications to treat the following possible conditions: *
How did you learn about these services? *
Additional information? *
Never submit passwords through Google Forms.
This form was created inside of Psychological Behavioral Health Inc.. Report Abuse