Fill out the form to REQUEST AN APPOINTMENT. A KSBH team member will contact you as soon as possible to confirm your appointment. If you are having an emergency, go to the ER or call 911. I am requesting an appointment for:(Required) Myself My child Another adult A patient (I am a referring provider) Your Name(Required) First Last Your Specialty(Required)Your Practice Name(Required)Prospective Patient's Name(Required) First Last Age of Prospective Patient(Required)Please enter a number from 1 to 99.Email(Required) Phone(Required)Preferred contact method(Required)EmailTextCallPreferred time to be contacted(Required)MorningAfternoonEveningPlease briefly describe patient's presenting symptoms(Required)What service(s) are you interested in?(Required) Individual Therapy Family or Couples Therapy Life Skills Family Skills Tailored Intensive Outpatient I'm not sure Referring for(Required) Adolescent IOP Young Adult IOP Individual Therapy Family Therapy Is the patient currently receiving, or has this patient ever received any of the above-mentioned services?(Required) Yes No Please explain which services and reason(Required)Is the patient presently prescribed medication?(Required) Yes No What provider / providers was this medication prescribed by?(Required) Family Practitioner Nurse Practitioner Psychiatrist Other Has the patient had a current drug screen?(Required) Yes No Was the drug test positive or negative and for what substance?(Required)What concerns are you experiencing?(Required)This field is hidden when viewing the formURLCommentsThis field is for validation purposes and should be left unchanged. Δ