Appointment Request Form - Bay Children's Services

Appointment Request Form

Note: We cannot honor requests for individual providers given high demand for services. If you request a specific provider, you may only be offered a spot on the waitlist.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Age Confirmation*
Please review and make sure this is the correct age of the patient. If not, please correct the date of birth.
Parent/Guardian Name*

First NameLast Name
What is your email address?*

Confirmation Emailexample@example.com
What is your mobile phone number?*
Reason for Seeking Services*
Which services have been recommended to you?*

Outpatient Therapy or Psychiatry
What services are you looking for?*

Individual TherapyParent and/or Family TherapyCouples TherapyGroup TherapyPsychiatry
Which of our locations are you requesting services for?*

BerkeleyBurlingameTelehealthAny
How did you hear about us?*
Please Select Your Insurance Carrier
Note! In California, Blue Cross and Blue Shield are separate companies, but in every other state they are combined. Make sure to select Blue Cross/Blue Shield ONLY if you have a non-CA plan
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