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

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City

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Group Number

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Policyholder Name and Date of Birth

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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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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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Transforming Body Image Group for Adults

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

Transforming Body Image Group for Adults

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