Appointment Request

If you are in an emergency situation or feel like you want to harm yourself or others, do not complete this form, instead seek immediate attention by calling one of the numbers below. 

• 911
• 211 for the local Crisis Center
• Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746. (TTY 1-800-846-8517)

Click here for additional emergency resources

Your request is very important to us. If you are interested in services, please answer the following questions and someone will respond as soon as possible.

If you are trying to schedule an appointment, all fields must be completed.

** Please note that BMH does not prescribe nor dispense psychotropic medications.

Name*

Address*

City, State, Zip*

Home Phone*

Cell Phone

Client Name*

Client Age

Referred By

Inquiring About? Current Problem/Situation (brief description)*

Is this affecting family, relationships, work, or school?

How long has this been a problem?*

Have you previously sought help for this problem?

Depression*

Yes

No

Anxiety*

Yes

No

Anger Problems*

Yes

No

Sleep Disturbances*

Yes

No

Suicidal Thoughts*

Yes

No

Suicide Attempts*

Yes

No

Homicidal Thoughts*

Yes

No

Substance Abuse*

Yes

No

Insurance Provider AND Policy Number*

Secondary Insurance Provider AND Policy Number

Policy Holder Date of Birth*

Client Date of Birth*

Preferred Appointment Type

In OfficeTelehealth/virtual session using your PC, Tablet or Phone

Telehealth is NOT the best option for you if you can answer yes to any of the following:
• You have thoughts of hurting yourself or others
• You are a minor or you are under the care of a legal guardian
• You are in an urgent crisis or an emergency situation
• You have been diagnosed with a severe mental illness, or if you have been advised to be in psychological supervision or psychiatric care
• You were required to undergo therapy or counseling either by a court order or by any other authority
• You do not have a device that can connect to the Internet or you do not have a reliable Internet connection

Comments

Email*

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