To request services, please answer the following questions: 
Psychological Behavioral Health Inc.
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Email *
Did a clinician agree to offer you services? If yes, please provide the name: *
What is the name of your primary insurance carrier? *
Is your insurance policy linked to a University or College? *
What is the age of the person of the person who is starting services? *
Phone number of the person who is starting services (or guardian/parent)? *
Do you consent to send and receive text messages on your phone and to have someone leave a voicemail? *
Do you consent to send and receive an email? *
Telehealth or in-person or no preference? *
For in-person services, what is you preferred city service area? *
Preferred days and times available to attend services? *
First name of the person who is starting services? *
Last name of the person who is starting services? *
Date of birth of person seeking treatment? *
To verify your insurance, we need your insurance ID *
To verify your insurance, what is the address connected to your insurance policy? (Address, City, State, and zip code) *
For medication and therapy services, we need two different email 
Services *
In a few sentences, please let us know the reason(s) for starting services? Therapists and staff will review the information. *
If you are a Kaiser member who is requesting medication services, please provide the authorization number and number of appointments authorized.
First and last name of the person completing this form? *
If you are filling out this form for someone, what is your relationship to the person? *
Parent or guardian first and last name? *
I would prefer that the clinician: *
What characteristics are important to you about the clinician? *
I am seeking services for the following: *
Preferred language of the person starting services? *
How did you hear about Psychological Behavioral Health Inc. *
Additional information? *
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