New Patient Appointments

New Patient AppointmentsSimply fill out the form

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New Patient Signup Form

Patient Contact Info

You will be asked to provide insurance info on the following pages. Please note that we do not accept medicaid.

Full Name(*)

Please type your full name.

Street Address(*)

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City(*)

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State(*)

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Zip Code(*)

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Date of Birth(*)

/ / Invalid Input

Home Phone Number(*)

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Cell Phone(*)

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Work Phone

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E-mail(*)

Invalid email address.

Parent or Guardian

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Gender(*)

Male Female Other Please specify your gender.

Referral Info
If you are not currently prescribed any medications, please write "None" in the appropriate field.

Referred By

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Reason for Referral

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Current Medications

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Primary Insurance Information

We accept the following forms of insurance: BCBS, Cigna, ComPsych, Consumer's Choice, Coventry, Magellan, Medcost, Medicare, MHNet, Multiplan, Tricare/Tricare Prime, and United Behavioral Health/United Health Care. We do not accept Medicaid.

All fields must be filled out. Please write "NA" in each field if you do not have insurance.

Insurance Company Name(*)

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Subscriber Name(*)

Invalid Input

Subscriber Social Security Number(*)

Invalid Input

Subscriber Date of Birth

/ / Invalid Input

Subscriber ID Number(*)

Invalid Input

Group Number(*)

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Insurance Company Phone Number(*)

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Secondary Insurance (if applicable)

All fields must be filled out. Please write "NA" in each field if you do not have insurance.

Insurance Company Name

Invalid Input

Subscriber Name

Invalid Input

Subscriber Social Security Number

Invalid Input

Subscriber Date of Birth

/ / Invalid Input

Subscriber ID Number

Invalid Input

Group Number

Invalid Input

Insurance Company Phone Number

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Please let us know how and when to contact you.

Best Number to Contact You(*)

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Are you interesting in seeing a:(*)

Psychiatrist
Psychotherapist (Counselor)
Both Invalid Input

In order to finalize the appointment, you will need to provide us with a Visa or MasterCard number. We won't use this number or charge anything before the appointment and we will delete it at your first appointment, but if you don't show up or give us a 24 hour notice, you will be charged $65.

Name on Credit Card(*)

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Credit Card Number(*)

Invalid Input

Expiration Month(*)

Invalid Input

Expiration Year(*)

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CVC Code(*)

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New Patient Forms

Once you have completed the online form here, print and fill out these forms. Bring them with you to your appointment in order to speed up your wait time.

Click Here

Helpful Links

Check out these helpful links for more information on many types of mental health issues and prescription drugs.

Click Here

Questions?

If you have questions about our office or
whether we take your insurance,
give us a call at (843)735-6799.

Call Now