Language
English (US)
Spanish (Latin America)
Submit Question
Please offer sufficient details so that we may promptly answer your question...
Please identify yourself:
*
Please Select
PBH Clinician Affiliate
Client
nonPBH Clinician
Interested Supervisee
Interested Supervisor
Community Member
Parent/Guardian
Insurance Representative
PBH staff or External contractor
First Name
*
Last Name
*
Email
*
Is your question about a Simple Practice chart?
*
Yes
No
Type a question
*
Billing
Scheduling
Start services
Current services
Supervision
Other
Copy and past the Simple Practice URL
*
For claim and billing inquiries, please provide the dates of service in question.
*
Submit your question or request.
How urgent is your question?
*
Please Select
1 - Critical - 24 hours (Also send an email to pbh@psychologicalbehavioralhealth.com)
2 - Urgent - Would like a response within 5 working days.
3 - Important - Would like a response within 10 working days.
4 - Would like a response within 14 working days.
Do you have any attachments?
*
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: