To refer a member for services, please answer the questions below. Scroll to the bottom and click "submit".
Psychological Behavioral Health Inc.
Email *
Are you a staff member? *
Your clinic/agency name? *
Name of person filling out this form? *
Which service does the member need? *
What is the member's preferred language? *
Member first name?
Member last name?
Date of birth *
If a minor, what is the first and last name of the parent or guardian? *
Phone number? *
Member Email
Primary insurance carrier name? *
Member Insurance ID
Additional information?
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