CBHS New Patient Registration Form

First Name(*)
First name is required

Last Name(*)
Last name is required

Date of Birth(*)
/ / Valid DOB is required

Gender(*)
Please choose a gender

Street Address(*)
Street address is required

Street Address 2
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City(*)
City is required

State(*)
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Zip Code(*)
Zip code is required

Cell Phone Number(*)
A valid Cell Phone Number is required

Email Address(*)
A valid Email Address is required

Primary Policy Holder Name(*)
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Primary Policy Holder DOB(*)
/ / Invalid Input

Parent/Guardian (if minor)
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Employer
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Primary Insurance Provider(*)
Insurance Provider name is required

Primary Policy Number(*)
Policy number is required

Primary Group Number(*)
Group number is required

Primary Insurance Company Phone Number(*)
Please only include the 10 number digits

Secondary Insurance?(*)
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Secondary Policy Holder Name(*)
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Secondary Policy Holder DOB(*)
/ / Invalid Input

Secondary Insurance Provider(*)
Insurance Provider name is required

Secondary Policy Number(*)
Policy number is required

Secondary Group Number(*)
Group number is required

Secondary Insurance Company Phone Number(*)
Please only include the 10 number digits

Reason for visit(*)

0

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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