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Welcome to DBH. We are glad you are here.
If you are new to DBH and would like to schedule an appointment, please fill out this form and someone from our scheduling team will contact you as soon as possible after we receive it.
Today's Date
/
Month
/
Day
Year
Date
Name (Last, First)
Date of Birth
/
Month
/
Day
Year
Date
Phone
Email
example@example.com
How would you like us to contact you?
Email
Phone
Text
Do you currently have a mental health provider?
Yes
No
Do you already know what services you need?
Psychotherapy/Counseling
Medication Management
Both
Don't Know/Not Sure
So that we can connect you with the right person on our team, please let us know briefly what brings you to DBH today.
Is there anything else you would like us to know?
If you are not the Patient, what is your relationship to the Patient
Parent/Guardian
Relative other than Parent/Guardian
Other
Parent/Guardian Name (if patient is under 18 years of age)
Parent/Guardian Phone (if patient is under 18 years of age)
Parent/Guardian Email (if patient is under 18 years of age)
example@example.com
Brief Description
Submit
Should be Empty: