Telehealth Provider Request
Please fill out the below information and you will be added to our Telehealth provider database. If you would like a copy of the list for your clients as a resource please email us at
cmclean@cottonwoodtucson.com
.
Summit Behavioral Health is still accepting new patients during this time and has implemented protocols under the guidance of the CDC to keep our patients and staff safe. For any additional questions or assistance with an admission please reach out to (888) 498-5589.
* Required
Full Name
*
Your answer
Email
*
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Website
Your answer
Phone number
Your answer
Insurance Accepted
Your answer
Type of Service
Medication Management
Mental Health Counseling
Addiction Counseling
Psychiatry
SUD Outpatient
Mental Health Outpatient
Intervention
Life Coaching
Case Management
Other:
Specialties
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
