New Patient Appointments

New Patient AppointmentsSimply fill out the form

Page 1 of 6

Step 1 of 2: Request a New Patient Appointment

Please complete the information below to schedule your initial appointment. Once completed, you can proceed to Step 2 of 2: The New Patient Medical History 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(*)

Invalid Input

City(*)

Invalid Input

State(*)

Invalid Input

Zip Code(*)

Please enter your 5 digit US zipcode.

Date of Birth(*)

/ / Invalid Input

Home/Primary Phone Number(*)

Invalid Input

Cell Phone

Invalid Input

Work Phone

Invalid Input

E-mail(*)

Invalid email address.

Parent or Guardian

Invalid Input

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

Invalid Input

Reason for Referral

Invalid Input

Current Medications

Invalid Input

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(*)

Invalid Input

Subscriber Name(*)

Invalid Input

Subscriber SSN

Invalid Input

Subscriber Date of Birth

/ / Invalid Input

Subscriber ID Number(*)

Invalid Input

Group Number(*)

Invalid Input

Insurance Company Phone Number(*)

Invalid Input

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

Invalid Input

"No Show" / Late Cancellation Fee

On the next screen, you will be required to provide a valid credit card.
You will receive an initial $0.50 charge for verification purposes. This is refunded to your card in 7 days, and no other charges or holds will be applied to your card UNLESS you fail to show up for your initial appointment or cancel the appointment without giving our office at least 24 hours advance notice. In the event of a No Show or late cancellation, the $65 fee will be charged to the card.

Please let us know how and when to contact you.

Best Number to Contact You(*)

Invalid Input

Step 2 of 2: Before Your First Appointment

The doctors require the medical forms to be filled out as soon as possible and at least 48 hours prior to the appointment. Please click below to fill out the secure online form.

New Patient Forms

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