New Client Enrollment_Adult

801-773-7060

24 Hour Crisis Line

Davis Behavioral Health provides services for Davis County, Utah residents only *

Yes, I am a resident of Davis County

Name of Person Making Contact *

Relationship to Client *

Client Name *

Primary reason for seeking services *

Email address *

Address *

City and Zip Code *

Phone Number *

Client is: *

Female Male

Date of Birth *

Primary language of person seeking services *

Insurance Company Name__Primary *

Policy or Member ID Number *

Policy Holder *

Policy Holder Date of Birth *

Relationship of Insured to Client *

Insurance Company Name__Secondary

Policy or Member ID Number

Policy Holder

Policy Holder Date of Birth

Relationship of Insured to Client

What services you are seeking: For substance use or MAT (suboxone, vivitrol) call Gerilyn at 801-336-1776 or email gerilynt@dbhutah.org *

Individual therapy / counseling Medication

List any previous mental health treatment including providers, where and when. *

List any previous psychiatric hospitalizations including providers, where and when. *

Primary physician of person seeking services. *