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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:
您的回答
Enter here how you would like us to contact you (phone number).
*
您的回答
Enter here how you would like us to contact you (email)?
*
您的回答
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.
*
您的回答
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
其他：
清除選取的項目
Is your insurance policy linked to a University or College?
Yes (You will need to get authorization from School Student Health Center)
No
清除選取的項目
What is the age of the person who is starting services?
您的回答
Do you consent to send and receive text messages on your phone and to have someone leave a voicemail?
Yes
No
清除選取的項目
Do you consent to send and receive emails?
Yes
No
清除選取的項目
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.
其他：
清除選取的項目
For in-person services, what is you city of residence?
您的回答
Preferred days and times available for services?
您的回答
I would prefer that the clinician identify as:
Male.
Female
No preference.
其他：
清除選取的項目
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.
其他：
清除選取的項目
In a few sentences, please let us know the reason(s) for starting services? Therapists and staff will review the information.
您的回答
If you are filling out this form for someone, what is your relationship to the person?
您的回答
What characteristics are important to you about the clinician?
您的回答
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
其他：
Preferred language of the person starting services?
您的回答
How did you hear about Psychological Behavioral Health Inc.
您的回答
Additional information?
您的回答
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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