CBHS New Patient Registration Form

First Name(*)
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Last Name(*)
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Date of Birth(*)
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Gender(*)
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Street Address(*)
Street address is required

Street Address 2
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City(*)
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State(*)
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Zip Code(*)
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Cell Phone Number(*)
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Email Address(*)
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Policy Holder Name(*)
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Policy Holder DOB(*)
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Insurance Provider(*)
Insurance Provider name is required

Policy Number(*)
Policy number is required

Group Number(*)
Group number is required

Insurance Company Phone Number(*)
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Reason for visit(*)

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Please enter a reason for your visit

Current Medications
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Referred By
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Requested Provider
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Previous Mental Health Provider
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Current or history of Substance Abuse(*)
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If Yes, please explain
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About Us

We are three board certified psychiatrists who specialize in evidence based treatments for Children, Adolescents and Adults. We are proud to offer a true continuum of services and the only group in the area to offer a comprehensive array of services including inpatient and outpatient.

© 2017 Comprehensive Behavior Health Services. All Rights Reserved.

The physicians at this practice typically do not make disability determinations.
Please refer to your family physician or obtain a referral from your primary physician to a disability specialist for assistance.

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