I wish to register my child to be a part of this group.

Patient First Name

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Patient Last Name

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Patient Date of Birth

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Parent One First Name

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Parent One Last Name

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Parent Two First Name

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Parent Two Last Name

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How did you about us?

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If you selected other, please state where you heard about us:

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Name of referring provider/office (PCP/Pediatrician, IOP/PHP, Hospital, Therapist, Psychiatrist, CBI Staff Member)

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Phone Number

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Secondary Phone (if applicable)

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Home Address

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Address Line Two

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City

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State

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ZIP Code

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I'd like to use commercial insurance

Insurance Name

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Member ID Number

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Group Number

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Provider Services Phone# for Insurance (on back of card)

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Policyholder Name and Date of Birth

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Yes - there is present use

I understand and will seek one of these or another service if needed

After completion of this form, a member of our administrative team will call you to set up a screening interview. When is the best time for a member of our administrative team to call and reach you to coordinate scheduling?

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Yes - my child is already established with a therapist outside of Cognitive Behavior Institute

If you are established with a therapist outside of CBI, please provide the name of the office and name of the therapist you see outside of CBI:

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Who is your current therapist at CBI?

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Is there anything else we should know?

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Section below is ONLY required if you would like to use commercial insurance

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Transforming Body Image Group for Parents & Preteens

Patient Information

Patient Information

Worker's Compensation

Worker's Compensation

Contact Information

Contact Information

Insurance & Payment

Insurance & Payment

***Section below is ONLY required if you would like to use commercial insurance***

Additional Screening

Additional Screening

Scheduling

Scheduling

Section below is ONLY required if you would like to use commercial insurance