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Psychological Behavioral Health Inc.
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Email
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Your email
Insured person's phone number?
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Your answer
First name of the person starting treatment?
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Your answer
Last name of the person starting treatment?
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Your answer
Date of birth of person starting treatment?
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Your answer
What is the age of the person who will be starting treatment?
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Your answer
The age of the person starting treatment is 6 to 17 years of age?
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No
First and last name of the person completing this form?
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Your answer
If a minor, what is the insured person's date of birth?
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Your answer
Preferred days and times to attend services?
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Your answer
Do you prefer a male or female clinician for therapy?
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Male
Female
No preference
Telehealth or in-person or no preference?
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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:
Services
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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:
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Can you send and receive text messages on your phone?
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Do you consent to send and receive an email?
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What is the name of your primary insurance carrier?
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Insurance ID?
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Your answer
What is your secondary insurance name and ID, if any? (or type none)
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Your answer
What is your insurance copayment?
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Your answer
Insured person home address, city, zip code, and state?
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Your answer
I would like to discuss medications to treat the following possible conditions:
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Not interested in medication
Depression
Anxiety
Obsessive-Compulsive Disorder
Bipolar
Attention-deficit/hyperactivity disorder
Panic Attacks
PTSD/Trauma
Schizophrenia
Eating Disorder
Anger
Autism Spectrum Disorder
Grief
Other:
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How did you hear about Psychological Behavioral Health Inc.
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Did one of the clinicians already agree to offer you services? If yes, please provide the name:
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In a few sentences, please let us know the reasons you are seeking services? We use this information to match you with a therapist.
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Additional information?
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