Intake Form

If the person filling out this form is the client, please put your name.  If the client is a child and the parent is completing the form, you must put the child client's name here and the email of the parent completing the form.  All answers to the form must be about the client and completed to the fullest ability.  Please allow for 10 to 15 minutes to complete.  If you have any questions please call 936-443-9629 or email frontoffice@pbhwc.com