Children's Behavioral Health

CBH website update form

Contact Information

Who should we contact if we have questions about the submission:

This form is to be used to notify CBH of additions, deletions or updates to services, or as a step in the process of an agency closure. To view your current listing, visit our Provider List

If you are making an update, or moving a service to a new location, please enter all the information for the service as it was prior to the update in the "Current Information" section; you can copy information which remains the same using the Copy button; for information which has changed, you may Copy and then edit, or type in the new data.

Your Current Agency Information
Item Current information Copy Updated information
Please enter all the "current" information; if the updated information is the same as the current, click on the copy checkbox; otherwise enter the updated information where appropriate in the right hand column.

Service information (including address/contact/phone)

Note: If you are adding multiple services to the same location, submit the form only once for each service. If all the address, contact information, etc is the same, simply select the new service provided, and "Submit" the form again.

If you are changing services, please use the "Remove a service..." option from the "I want to" dropdown above and then "Add a service..." for the new service(s).
NPI+3 &
Billing Location:
NPI+3# Billing Location

(Contact listed on web page)

(enter 'None' if no website)

(enter 'None' if no website)
Counties/areas served:
Counties Served


Counties Served