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INTAKE/ADMISSION

Interested in our programs?

Platform Behavioral Support Services provides many programs and services in Houston and surrounding cities. To make an appointment with us, don't hesitate to contact a member of our Intake Department by calling 713-360-7375 or emailing us at Info@platformbehavioral.com. 

For all programs & services of Platform Behavioral Support Services:
Open from Monday to Friday, 9:00 am to 5:00 pm Saturday - as needed
Phone: 713-360-7375
Email: info@platformbehavioral.com

*REQUIRED INFORMATION
May we leave a message?
Gender
Race /Ethnicity
Marital Status
Do you understand any other language?
Do you need communication assistance?
Highest School Education
Employment
List all medications and Prescribers
Presenting Problems (Check all that apply below)
Note: If suicidal, homicidal, gravely impaired or need further clinical guidance contact a licensed clinician to further assess for triage! Document clinical disposition when applicable.
Are you allergic to any medications?
Do you have any other allergies?
Are you currently pregnant?
Are there any medical problems that you are currently receiving treatment for?

 I voluntarily consent to the administration of treatment for myself or my dependent.
I have read my Consent for Treatment.

                                                              I authorize payment directly to Platform Behavioral Support Services for services provided.

                                   I authorize or request l Platform Behavioral Support System to release or obtain my confidential medical information (verbal or in writing) to or from any person, provider, health insurance company or organizations involved in my healthcare for quality management, utilization review, treatment purpose, transfer, and follow-up purposes.

                                                    I acknowledge that I have received and read the Notice of Privacy Practices.

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