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Your answers to the following questions will be reviewed by the PBH billing team and clinicians. Information remains confidential within PBH and is not sold to outside entities.
Psychological Behavioral Health Inc.
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Answering Questions Online
You have the option to only answer the questions you wish to answer. Please keep in mind that clinicians do rely on the information to make decisions about offering services.
Did a clinician agree to offer you services? If yes, please provide the name:
Your answer
Enter here how you would like us to contact you (phone number).
*
Your answer
Enter here how you would like us to contact you (email)?
*
Your answer
To protect your identity, please provide us with an alias name (fake name). When we call contact you, we will ask for the name you provide. This way only you will know why a clinician is calling.
*
Your answer
What is the name of your primary insurance carrier?
Aetna
Anthem Blue Cross California
Blue Shield
Cigna or Evernorth
Kaiser Permanente
Gold Coast Health or Beacon or Carelon
MHN
Optum
Oscar Health
Oxford
United Healthcare
Other:
Clear selection
Is your insurance policy linked to a University or College?
Yes (You will need to get authorization from School Student Health Center)
No
Clear selection
What is the age of the person who is starting services?
Your answer
Do you consent to send and receive text messages on your phone and to have someone leave a voicemail?
Yes
No
Clear selection
Do you consent to send and receive emails?
Yes
No
Clear selection
Telehealth or in-person or no preference?
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:
Clear selection
For in-person services, what is you city of residence?
Your answer
Preferred days and times available for services?
Your answer
I would prefer that the clinician identify as:
Male.
Female
No preference.
Other:
Clear selection
Services
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:
Clear selection
In a few sentences, please let us know the reason(s) for starting services? Therapists and staff will review the information.
Your answer
If you are filling out this form for someone, what is your relationship to the person?
Your answer
What characteristics are important to you about the clinician?
Your answer
I am seeking services for the following:
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:
Preferred language of the person starting services?
Your answer
How did you hear about Psychological Behavioral Health Inc.
Your answer
Additional information?
Your answer
Thank you for submitting your information.
Staff will review your information and contact you if there is a clinician available. If a clinician is not available, you will be added to the waiting list.
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