Responses to the following questions will be reviewed by PBH Network clinicians and the PBH Billing Team. 
Psychological Behavioral Health Inc
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Answering Questions Online
You choose what to write. Please remember that clinicians reference this information to make service decisions.
What is the name of your primary insurance carrier?
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Did a clinician agree to offer you services? If yes, please provide the name:
If you are an insurance representative, please provide information here that would like clinicians to review.
Please add your phone number if you authorize a phone call or write NA. *
Please add your email address if you authorize email or write NA.
To protect your identity, please provide us with only your initials. We will refer to the initials when the clinicians calls you.   *
Is your insurance policy linked to a University or College?
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What is the age of the person who is starting services?
Do you consent to send and receive text messages on your phone and to have someone leave a voicemail?
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Do you consent to send and receive emails?
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Telehealth or in-person or no preference?
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When choosing in-person services, what is your city of residence.
Preferred days and times available for services?
I would prefer that the clinician identify as:
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Services
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In a few sentences, please let us know the reason(s) for starting services? Therapists and staff will review the information.
If you are filling out this form for someone, what is your relationship to the person?
What characteristics are important to you about the clinician?
I am seeking services for the following:
Preferred language of the person starting services?
How did you hear about Psychological Behavioral Health Inc?
Additional information?
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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