Appointment Request
Psychological Behavioral Health Inc
Your responses will be reviewed by Clinicians and the Billing Team.
Relationship to Client
*
Please Select
Self
Parent/Guardian
Insurance Representative
PBH staff and contractors
What is the method of payment?
*
Please Select
Insurance
Self-Pay
Primary Insurance
Please Select
Aetna
Anthem Blue Cross California
Blue Shield
Cigna or Evernorth
Health Net
Kaiser Permanente - Southern
Magellan Health
Med-Cal - CalViva
Medi-Cal - Gold Coast Health (Carelon)
Medi-Cal - LA Care
Medicare
Optum
United Healthcare
Other not listed
Other Insurance:
Client Information
First Name
*
Last Name
*
Date of Birth
-
Month
-
Day
Year
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Age of the person starting services?
*
Language preference?
*
Client's sex per insurance policy
*
Please Select
Male
Female
Email
Zip code
*
Phone Number
Please enter a valid phone number.
Service Requested
Service Request:
*
Medication services.
Therapy services.
Therapy and medication services.
Medication services. Therapy is currently active with a therapist.
Medication services. I plan to find a therapist elsewhere.
I am not sure.
How would you like to communicate during the consultation?
*
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
Seeking services for:
*
I prefer not to share at this time
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
Other
Did a clinician agree to offer you services? If yes, please provide the name
*
Yes
No
Please provide the name:
*
Is your insurance policy linked to a University or College?
*
Yes (You will need to get authorization from School Student Health Center)
No
Enter available days and times to meet:
*
I would prefer that the clinician identify as (Optional):
Male
Female
No preference
Other
Please provide any additional information that you would like to share with therapist and billing team (optional).
Additional information (Optional).
Insurance Representative
PBH will send confirmation for both scheduled and completed appointment.
Insurance Representative Name
First Name
Last name
Insurance Representative Phone #
Phone Number
Extension
Insurance Representative Email
Receive email confirmation
Insurance representatives, please provide information for clinicians.
Authorized Consent
(Client or Guardian)
Name (Authorized to consent)
*
First Name
Last Name
Email (Authorized)
*
Phone Number
*
Phone Number
Consent to communicate:
*
Telephone, Email, Text messages
Other
Thank you for submitting your information.
Date Submitted
*
-
Month
-
Day
Year
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Electronic Signature
*
I understand and consent to submitting my information online to initiate mental health services. I also consent to receiving electronic communications regarding my account and services. Your contact information will be shared with Psychological Behavioral Health Inc and Psychological Behavioral Team Inc and for service communication.
Submit
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