Male Behavioral Health – Brief Consultation Form

Thank you for your interest in a new patient appointment with Male Behavioral Health (MBH). Please complete this brief form so we can match you with the clinician and appointment time that best fit your needs. You will be contacted shortly to schedule your consultation.

Sign in to Google to save your progress. Learn more
Email *
Information

Full Name: 

Phone Number: 

Email Address:  *
Preferred Contact Method: *
Required
Availability
Preferred Days: *
Required
Preferred Time of Day:  *
Available for brief phone consultation (10–15 minutes)? *
Insurance and Payment Information

Do you plan to use insurance for services? 

 *
Insurance Provider: *
If not using insurance, how do you plan to pay for services? *
Would you like more information about sliding scale or payment options? *

Once submitted, a member of our team will contact you to schedule your appointment.

Thank you for choosing Male Behavioral Health — helping men, boys, and families build healthier lives and stronger communities.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of mbhinc.com.

Does this form look suspicious? Report

Google Forms