Toll Free
(855) TEAMPBS
+1-855-832-6727

Request Team PBS Services

Please complete the fields below and we will be in touch within two business days.

Client Information | this is the person who will be receiving services

Required
Required
Required
Required Invalid date.Date of birth can not be future date.
Required
Required

Parent/Guardian Information | parent details

Required Invalid Email

This email is already registered. If you want to continue using this email, please log in to parent portal. Else change the email.

Required
Required
Required Invalid date of birth. Age must be more than 18 years. Date of birth can not be future date.
Required
Required
Required
Required
Required Invalid zip.
Required Invalid Phone number
Invalid Phone number
Invalid Phone number
* Used only for internal communications & billing purpose

Parent/Guardian Information II | parent details II

This email is already registered. If you want to continue using this email, please log in to parent portal. Else change the email.

Required Invalid date of birth. Age must be more than 18 years. Date of birth can not be future date.
Required
Required Invalid zip.
* Used only for internal communications & billing purpose

Caregiver Availability | what days and times would work best for you?

Times
06:00 - 06:30 AM
06:30 - 07:00 AM
07:00 - 07:30 AM
07:30 - 08:00 AM
08:00 - 08:30 AM
08:30 - 09:00 AM
09:00 - 09:30 AM
09:30 - 10:00 AM
10:00 - 10:30 AM
10:30 - 11:00 AM
11:00 - 11:30 AM
11:30 - 12:00 PM
12:00 - 12:30 PM
12:30 - 01:00 PM
01:00 - 01:30 PM
01:30 - 02:00 PM
02:00 - 02:30 PM
02:30 - 03:00 PM
03:00 - 03:30 PM
03:30 - 04:00 PM
04:00 - 04:30 PM
04:30 - 05:00 PM
05:00 - 05:30 PM
05:30 - 06:00 PM
06:00 - 06:30 PM
06:30 - 07:00 PM
07:00 - 07:30 PM
07:30 - 08:00 PM
08:00 - 08:30 PM
08:30 - 09:00 PM
09:00 - 09:30 PM
09:30 - 10:00 PM
10:00 - 10:30 PM
10:30 - 11:00 PM
11:00 - 11:30 PM
11:30 - 12:00 AM

Tutorial:

Click once to select/unselect box.

Click and drag to select more box at once.

Click day to select all times available

Payment Source | how would you like to pay for services?

Required
Required

Card Upload | upload your card images

Required File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.
Required File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.
If your card is on a single image please upload it in both places.
Required
Required

Diagnosis | upload your diagnosis images

File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.

Additional Services | check out additional services we offer

Captcha | verify to prevent spam

Re-entered Last Name does not match with the Last Name. Required