Behavioral Health Consultation

Las Vegas Behavioral Health Intake

Intake Form

Patient Name *

Guardian. This is a vital component especially for a minor-aged patient.

Email address *

Phone number. For follow-up, scheduling, rescheduling, and cancelling appointments. *

Provider. Recent medical provider should be included to indicate who the patient has last seen and is responsible for any incorrect procedures and treatments.

Insurance Information/provider or policy number

Please select at least one option.

I allow this website to store my submission so they can respond to my inquiry. *

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