Behavioral Health Screening
Name of person seeking services
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Tribal affiliation
Current HHS client or need to register?
Current
Need to register
Main reason for seeking BH services?
Urgent or emergency needs (risk of harm to self or others, need for inpatient care or urgent medical needs)
Current employee of NHBP government or child/household member of a current employee?
Yes
No
Is this person a minor? If so, please list the guardian’s name and contact info
Prefer In-Person or Telehealth
In Person
Telehealth
Any requests regarding specific providers, preferences or other info:
Submit
Should be Empty: