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Psychological Behavioral Health Inc.
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Email
*
Your email
Did a clinician agree to offer you services? If yes, please provide the name:
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Your answer
What is the name of your primary insurance carrier?
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Aetna
Anthem Blue Cross California
Blue Shield
Cigna or Evernorth
Kaiser Permanente
Gold Coast Health or Beacon or Carelon
Medicare
MHN
Optum
Oscar Health
Oxford
Pinnacle Claims Management
Regal Medical Group
Tricare
United Healthcare
Western Growers
Test
Other:
Is your insurance policy linked to a University or College?
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Yes (You will need to get authorization from School Student Health Center)
No
What is the age of the person of the person who is starting services?
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Your answer
Phone number of the person who is starting services (or guardian/parent)?
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Your answer
Do you consent to send and receive text messages on your phone and to have someone leave a voicemail?
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Yes
No
Do you consent to send and receive an email?
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Yes
No
Telehealth or in-person or no preference?
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Telehealth is preferred
In-person is preferred.
I am ok with either telehealth or in-person.
I need to meet with a therapist in-person or I am not interested.
Other:
For in-person services, what is you preferred city service area?
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Your answer
Preferred days and times available to attend services?
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Your answer
First name of the person who is starting services?
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Your answer
Last name of the person who is starting services?
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Your answer
Date of birth of person seeking treatment?
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MM
/
DD
/
YYYY
To verify your insurance, we need your insurance ID
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Your answer
To verify your insurance, what is the address connected to your insurance policy? (Address, City, State, and zip code)
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Your answer
For medication and therapy services, we need two different email
addresses.
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Your answer
Services
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Interested in only medication services.
Interested in only therapy services.
Interested in therapy and medication services.
Interested in only medication services. Therapy is currently active with a therapist.
Interested in only medication services. We plan to find a therapist.
I am not sure.
Other:
In a few sentences, please let us know the reason(s) for starting services? Therapists and staff will review the information.
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Your answer
If you are a Kaiser member who is requesting medication services, please provide the authorization number and number of appointments authorized.
Your answer
First and last name of the person completing this form?
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Your answer
If you are filling out this form for someone, what is your relationship to the person?
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Your answer
Parent or guardian first and last name?
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Your answer
I would prefer that the clinician:
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identify as a male.
identify as a female.
No preference.
Other:
What characteristics are important to you about the clinician?
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Your answer
I am seeking services for the following:
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Aggression
Anger
Anxiety
Attention-deficit/hyperactivity disorder
Autism Spectrum Disorder
Bipolar
Depression
Eating Disorder
Grief
Identity Related Concerns
Learning Challenges
Marital Concerns
Medication Services
Not interested in medication
Obsessive-Compulsive Disorder
Oppositional Defiant
Panic Attacks
PTSD/Trauma
Schizophrenia
Other:
Required
Preferred language of the person starting services?
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Your answer
How did you hear about Psychological Behavioral Health Inc.
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Your answer
Additional information?
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Your answer
Send me a copy of my responses.
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