Language
English (US)
Spanish (Latin America)
Request Appointment
Your request will be reviewed by Clinicians and the Billing Team.
Relationship to Client:
*
Please Select
Self
Parent/Guardian
Insurance Representative
Carelon Representative
Provider/Clinician
Relationship to Client
What is the method of payment?
*
Please Select
Insurance
Self-Pay
What is the method of payment?
Primary Insurance:
*
Please Select
Aetna
Anthem Blue Cross California
Blue Shield
Carelon
Cigna/Evernorth
Health Net
Kaiser Permanente - Southern
CalViva
Gold Coast Health Plan
LA Care
Medicare
Optum
Optum EAP
Optum Medicare
United Healthcare
Other not listed
Primary Insurance
Member ID (Primary):
Member ID (Primary)
Secondary 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
Secondary Insurance
Member ID (Secondary):
Member ID (Secondary)
Other Insurance:
Other Insurance:
Member ID (Other):
Member ID (Other)
Parent/Guardian
Last Name:
*
First Name:
*
Parent Email:
*
Parent Phone Number:
*
Format: (000) 000-0000.
Type a question
*
English
Espanol
Other
Client Information
Last Name:
First Name:
Date of Birth:
-
Month
-
Day
Year
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Client Age:
*
Client Language:
Client's sex per insurance policy:
*
Please Select
Male
Female
Unknown
Client Email:
Client Phone Number:
Format: (000) 000-0000.
Zip code:
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?
Virtual is preferred
In-person is preferred
I am ok with either virtual 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 services? If yes, please provide the name:
Yes
No
Please provide the name:
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
Unknown
Enter available days and times to meet:
Enter available days and times to meet:
I would prefer that the clinician identify as (Optional):
Male
Female
No preference
Other
Additional information for the therapist and billing team (Optional):
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:
Insurance Representative Phone #:
Format: (000) 000-0000.
Insurance Representative Extension:
Insurance Representative Email:
Receive email confirmation
Insurance representatives, please provide information for clinicians:
Insurance representatives, please provide information for clinicians.
Contact Authorization
Name (Authorized to consent):
Email (Authorized):
Phone Number:
Format: (000) 000-0000.
Consent to communicate:
Telephone, Email, Text messages
Other
Thank you for submitting your information
Date Submitted
*
-
Month
-
Day
Year
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Hour Minutes
AM
PM
AM/PM Option
Electronic Signature
*
By submitting this information, I consent to the initiation of mental health services and the secure electronic processing of entered data. I authorize Psychological Behavioral Health Inc to share necessary clinical and demographic information with affiliated providers, administrative staff, and insurance carriers for the purposes of care coordination, scheduling, and claims reimbursement. I also consent to receiving electronic communications regarding my account and services.
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