Eligibility Assistance Form

Please provide the following information below. All information is secure and encrypted for your protection. A qualified representative of Brooks Behavioral Health Center will be in contact with you within the next twenty four (24) hours. Thank you for expressing an interest in our services, we look forward to assisting you in the near future.

Should you require more immediate assistance, please contact our operators at 702.570.5200

Patient Information

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Family Member #1


Family Member #2


Family Member #3


Is This The First Visit To Our Offices?*

Do You Require Transportation?*


Appointment Information

Please provide any additional information or comments below. BBHC, LLC will not release any privileged information in any form. All information given is for eligibility inquires only.