Initial Outpatient Mental Health Treatment Request Form


Fields marked with an asterisk are required. The certification is not valid until CBA issues a certification number.

Clinician Information

Outpatient clinics please use same NPI for both fields.

Phone () -
Fax () -
Patient Information


Phone () -
Clinical Information
What Service(s) Are You Requesting? (Check all that apply.)

Diagnosis or Presenting Symptoms:
Max characters: 200