Interested in services? Please complete the following form. A staff member will contact you.
Prescriptive Behavioral Health
Email address *
Insured person's phone number? *
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Services (Dr. Bimbela is only offering medication services) *
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Does your phone number accept text messages? *
What is the name of your insurance carrier? *
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Insurance ID? *
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What is your insurance copayment? *
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Insured person home address, city, zip code, and state? *
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Parent date of birth (insured)? *
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First and last name of the person completing this form (Adult/Guardian)? *
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First and last name of the person starting treatment (Child-Adolescent)? *
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Date of birth of person starting treatment? *
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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? *
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What is the reason(s) for starting treatment? *
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I would like to discuss medications to treat the following possible conditions: *
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How did you learn about this services? *
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Additional information? *
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