Service Inquiry:

Prospective persons, families, and organizations are encouraged to complete our inquiry form . If you have additional questions or have difficulty completing the form, please contact us by phone or email.

Insurance/Other Payors:

Perch Behavioral Health is contracted with most major insurance carriers including, but not limited to: Premera, Kaiser Permanente, Regence, First Choice, Blue Cross Blue Shield, Cigna, Anthem, United, and Tricare. Perch proudly accepts Medicaid members and benefits through state waivers.

Perch Behavioral Health works proudly in both the public and private school district setting throughout the Puget Sound area.

Office Phone/Fax/Email/Address:

Phone: 206-580-6940

Fax: 253-944-9062

Email: info@perchbehavioralhealth.com

Address: 3909 California Avenue SW, Suite 201, Seattle, WA, 98116

Contact Name

First Name

Last Name

Email Address

Phone

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Date of Birth

YYYY

Social Security Number

Primary Insurer Name

First Name

Last Name

Date of Birth

YYYY

Social Security Number

Primary Insurance

Secondary Insurance

Primary Insurer Employer

Member ID

Group ID

Customer Service Number (Providers)

(###)

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Diagnosis

Describe Your Main Concerns In Regards To Your Child

Describe Your Child's Communication Skills

Past Services Received

Speech Therapy

Occupational Therapy

A.B.A. Therapy

None

Services Currently Receiving (Indicate Days/Times of Sessions)

School Schedule

Summer Schedule

Does Your Child Nap (If Yes, How Long & Time of Day)

Are There Pets In The Home

If Yes, What Type Of Pet

Does Anyone Smoke In The Home

Are There Firearms In The Home

If Yes, Are They In A Lockbox

How Did You Hear About Us