Adult New Patient Appointment Request
Please fill in this form in order to request an appointment with our office. Mandatory fields are marked with an asterisk (*).
Contact Information
Guardian's Name
*
First Name
Last Name
Guardian's Email
*
Confirmation Email
example@example.com
Patient's Name
*
First Name
Last Name
Patient's Gender
Male
Female
Other
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
What phone number is this for you?
Home
Cell
Work
Other
Alternate Phone Number
-
Area Code
Phone Number
What phone number is this for you?
Home
Cell
Work
Other
What is the best time to contact you?
Morning (8:30-12)
Afternoon (12-4)
Early evening (4-6)
Primary Insurance Carrier
*
Aetna
BCBS
CareSource
Cigna
Humana (NOT TRICARE)
Medicaid
Self Pay
Peachstate
Insurance Type
PPO
POS
HMO
Self Pay
Insurance ID Number:
*
Insurance Group Number (if applicable):
Number on back of insurance card for providers or customer service:
*
Name of Parent who provides insurance (if applicable):
Date of Birth of Patient or Guardian who provides insurance (if applicable):
-
Month
-
Day
Year
Date
Address of Parent Who Provides Insurance:
Same As Child
Other (Please provide below)
Parent's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Carrier
Aetna
Ambetter
BCBS
Beacon (Out-Of-Network
CareSource
Cigna
Humana
Medicaid
Optum (Out-Of-Network)
Peachstate
United Healthcare
Value Options (Out-Of-Network)
If other, please list other insurance:
Secondary Insurance ID Number:
Secondary Insurance Group Number (if applicable):
Appointment Preferences
Requested Provider:
Next Available
Dr. Jaymie Fox
Dr. April Coleman
Dr. Ria Travers
Dr. Brittany Duncan
Jennifer Cohrs, LPC
Referring Provider:
*
Referring Provider Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Provider Phone Number
*
-
Area Code
Phone Number
Referring Provider Fax Number
*
-
Area Code
Phone Number
Preferred Appointment Time/Days
Morning (9-12)
Afternoon (12-4)
Monday
Tuesday
Wednesday
Thursday
Reason for Referral:
Autism Spectrum Disorder
ADHD
Learning Challenges
Developmental Delays
Gifted
Therapy
Other
If other, please list reason:
Submit to GAC
Should be Empty: