New Patients

New Patient Appointment & Intake Form

Complete this form to begin your care at PBHC. Our team will contact you within 1–2 business days.

Personal Information

Full Name *

Date of Birth

Phone Number *

Email Address *

Home Address

Insurance Information

Insurance Provider

Member ID

Clinical Information

Primary Concerns / Reason for Visit *

How Did You Hear About Us?

HIPAA Consent

By submitting this form, you acknowledge that the information provided will be used by Passionate Behavioral Health Center to schedule your appointment and coordinate your care. Your information is protected under HIPAA and will not be shared without your written authorization except as required by law.

I understand and consent to the collection and use of my information as described above. *

Fields marked * are required. We'll respond within 1–2 business days.