Telehealth Appointment Request

How Can We Help? *
Mental HealthSubstance Use Disorder

Full Name *

Date of Birth *

Phone *

Your email *

Street Address*

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Preferred Method of Contact *
PhoneEmailText

Preferred Language

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship *

Consent and Signature
I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this form does not guarantee an appointment and that a staff member from FBHC will contact me to schedule.

Inputting my name below represents my signature.

Signature *