JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Pittsburgh Behavioral Services (PBS) Inquiry Form
This form is to be used by anyone seeking information and/or services by PBS. All information recorded by this form will be kept confidential and only PBS staff will have access to your responses. Please answer any relevant field.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
I am completing this form
*
In the interest of a family member
As a service/support provider
Other:
Your name and role (e.g., clinician, colleague, agency if applicable):
*
Your answer
Name of learner (if applicable):
Your answer
Learner's DOB:
MM
/
DD
/
YYYY
Preferred contact phone number:
*
Your answer
Preferred contact email:
*
Your answer
How did you hear about PBS?
*
PBS staff referral
ACAC referral
Online search
Friend or family referral
Professional referral
Other:
What services are you interested in learning more about? (Select all that apply)
Intensive Clinical Program (ages 1-7)
Assessment Only Program
Collaborative School Consultation
External/Expert Consultation (no regular direct implementing team)
School-aged Support Options
Parent/Family Training
ABA PGH Pre School/Kindergarten School Programs
Partner Program Support (ACAC/ SEAPC)
What frequency of services are you committed to attend? (e.g., one-time, weekly, daily)
Your answer
Are you familiar with the differences from our service model with competitors?
Yes
No
Clear selection
What are the learner's greatest areas of need?
Your answer
Does the learner have an educational or medical diagnosis for receiving services? If so, what?
Your answer
Is the learner currently in a period of life where problem behavior is interfering with quality of life? If yes, what behaviors/how long?
Your answer
Has the learner received services in the past?
Yes
No
Clear selection
Has anyone in the learner's family received services in the past?
Yes
No
Clear selection
Is the learner currently receiving services from other providers? If so, who and for what?
Your answer
Additional comments:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pittsburgh Behavioral Services.
Report Abuse
Forms
