New Clients, Patients, Psychology, Mental Health, Behavioral Health, Medicaid

REQUEST A NEW APPOINTMENT
An Appointment Request Form will be emailed to you. Please check your junk mail too.
Once our office reviews your form, we will reach out to you with scheduling options.
You can also call 936-443-9629 or email frontoffice@pbhwc.com to let us know you completed your request.
In addition to this request form, clients will also be required to complete our History and Consent Forms,
which will be sent to you electronically if accepted as a client.

Instructions

Please click the appropriate link. If you are not sure, call our office. 936-443-9629
Make sure you have at least 15 minutes available to complete the form.
In the "Please put your name and email" section, please put the patient's name and email of person completing the form. This email will be used to send you a password in case you need to log back in and complete the form later.
Please complete the form as detailed as you can. If something is required but does not apply to you type "NA."
You can stop the form and log back in to complete at any time but it will give you a password in an email that you provided in step 2.
You can choose to print the form out and complete it by hand. Just remember to bring it in to your appointment.
If you do not complete the form prior to your appointment, please come at least 15 minutes early to your appointment. If you are 15 minutes late in starting your appointment, you will be asked to reschedule and charged the late arrival fee of $65.

REGULAR
CHILD INTAKE FORM

DO NOT FILL OUT FORMS WITHOUT CALLING OUR OFFICE FIRST. 936-443-9629

OUR OFFICE WILL NOT BE NOTIFIED THAT YOU SUBMITTED A FORM UNLESS YOU CALL OUR OFFICE AND WE GIVE YOU PROPER INSTRUCTIONS AND WE COLLECT NEW CLIENT INFORMATION FIRST.

FORENSIC ADULT
INTAKE FORM

These forms need to be completed prior to your session. If you do not, please come to your appointment 15 min early. If paperwork cuts into the appointment time more than 15 min, you will be asked to reschedule the appointment and changed $65 due to our late reschedule late arrival policy.

OTHER PARTY INVOLVED IN
CHILD'S COURT ORDER
CONSENT TO SERVICES

REGULAR
ADULT INTAKE FORM

FORENSIC JUVENILE
INTAKE FORM

Instructions

Please click the appropriate link. If you are not sure, call our office. 936-443-9629
Make sure you have at least 15 minutes available to complete the form.
In the "Please put your name and email" section, please put the patient's name and email of person completing the form. This email will be used to send you a password in case you need to log back in and complete the form later.
Please complete the form as detailed as you can. If something is required but does not apply to you type "NA."
You can stop the form and log back in to complete at any time but it will give you a password in an email that you provided in step 2.
You can choose to print the form out and complete it by hand. Just remember to bring it in to your appointment.
If you do not complete the form prior to your appointment, please come at least 15 minutes early to your appointment. If you are 15 minutes late in starting your appointment, you will be asked to reschedule and charged the late arrival fee of $65.

The first link is for the parent/guardian who initiated mental health services for a child involved in a court order, custody agreement, possession order, adoption agreement, or divorce decree. This parent/guardian must upload or submit the court order and divorce decree to this office prior to scheduling an appointment.

The second link is for the other person involved in the child's court order to give written consent of mental health services or to prove that the initiating parent/guardian notified the other person involved of services being sought. If the orders specify that both parties need to be notified or consent, both of these forms/links need to be completed and submitted before this office will schedule the child's first appointment.

It is the person initiating services who is responsible for getting this office the court order, divorce decree, and to make sure the other party involved completes their intake/consent form. If the court order or divorce decree states that the initiating parent/guardian has the sole ability to consent and does not need to notify other party, then this office will not need the other party to complete the second link.

FORENSIC

EVALUATION OR COUNSELING INTAKE FORM

PARENT/GUARDIAN
INITIATING SERVICES COMPLETES
THIS FORM FOR CHILD IN LEGAL SITUATION

REGULAR

EVALUATION OR COUNSELING

INTAKE FORM

If child's biological parents are not legally married, this section is for you.

CHILD WHO'S PARENTS

ARE NOT MARRIED,

INVOLVED IN A COURT ORDER,

ADOPTION, OR DIVORCE

EVALUATION OR COUNSELING INTAKE FORM

Instructions

Please click on the link below from "Intake Q" for "Parent/Guardian Initiating Services" and allow at least 15 minutes to complete the form.
In the "Please put your name and email" section, please put the patient's name and email of person completing the form. This email will be used to send you a password in case you need to log back in and complete the form later.
You must upload a copy of most current court order. If child is of divorced parents, then you must also include most current divorce decree too. If you do not upload required paperwork into this intake form, you can email it to info@prevailcounseling.com or bring it by our office before scheduling the child's appointment. It is the initiating parent/guardian's responsibility to provide the most current court orders and/or divorce decree to this office.
Please complete the form as detailed as you can. If something is required but does not apply to you type "NA."
You can stop the form and log back in to complete at any time but it will give you a password in an email that you provided in step 2.
You can choose to print the form out and complete it by hand. Just remember to bring it in to your appointment.
THE PERSON INITIATING SERVICES MUST CONTACT THE OTHER PARTY OR PARENT AND GIVE THEM INSTRUCTIONS ON HOW TO FILL OUT THIS FORM.
The person initiating services must call this office back once all forms are complete and court orders delivered to this office to schedule the first appointment.