New Patient AppointmentsSimply fill out the form

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New Patient Signup Form (inactive)

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(*)
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Home Phone Number(*)
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Cell Phone
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Work Phone
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E-mail(*)
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Social Security Number(*)
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Parent or Guardian
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Gender(*)
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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If none, please indicate "none."

 

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(*)
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Subscriber Social Security Number(*)
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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)

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 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

 

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:(*)

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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