Serving The Hawaiian Islands

+1 808-585-1424

Make a Referral
Patient Login

About Us
Programs & Services
Resources
Join Our Team
Our Contacts

aba

Preschool girl painting in art class. Close up photo brush in hand

By HBH Latest News

Art and Autism

Historically, art therapy has been a highly successful component of psychotherapy for all age groups and backgrounds.

Contact Us
Privacy Policy
Terms of Service

2021 © Hawaii Behavioral Health

Client Intake Information Sheet

Client Information

Name

Date of Birth

Address

Parent Name

Parent Phone

Parent Email

Insurance Policy Holder Information

Policy Holder

Date of Birth

Employer

Primary/Secondary Insurance

Subscriber/Membership#

Group#

Type of Insurance

Quest HMO PPO

Insurance Eligibility

Yes No

Co-Payment

Treatment / Services

Qualifying Diagnosis received?

Yes No

Time when Client is available for services?

When would you like services to start?

Comments?

Does the Client currently receive HBH Services and/or works with an HBH provider?

Provider Name

Type of Service