Schedule An Appointment

Schedule An Appointment

Enter your details to receive a call back from us.
Full Name

First NameLast Name
Date of Birth
Ex: mm/dd/yyyy
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Administrative Sex
Gender Identity
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider [if you plan to pay direct rate, please put none]
Insurance ID and Group Number [if you plan to pay direct rate, please put none]
Are you the primary subscriber?
If not, who is?
Include Name, DOB and Relationship to Patient
I understand that if I choose to use self-pay rather than insurance, the rate is $175 for the initial intake appointment and $125–$150 for each subsequent session. Alternatively, I may opt to work with an intern at a rate of $50 per session or apply for the sliding fee scale to determine if I qualify for reduced-rate sessions with a clinician at the practice.
Marital Status
Employment Status
Group Therapy Preference (If Applicable)?
Which location would you prefer? (Select all that apply)
What is your time preference? (Select all that apply)
What days of the week do you prefer? (Select all that apply)
How soon do you want your appointment?
How did you hear about us?

Other
Please provide a general idea of what you are seeking support for. This is not required, but it helps us match you with the clinician whose specialties and areas of expertise best align with your needs.You are also welcome to share any additional preferences you may have when being matched with a counselor. While we may not always be able to accommodate every preference, we will do our best to find the right fit for you.
I understand that if my address is located in Kentucky, I may only receive in-person services at an office located in Tennessee. For virtual appointments, I understand that I must be physically located in Tennessee at the time of the appointment unless I am assigned to a clinician who is specifically licensed to provide services in Kentucky.
I understand that by completing this form, if an agreed-upon date and time are reserved for me, I am subject to the practice’s cancellation policy. Should I fail to attend my scheduled appointment or cancel with less than 24 hours’ notice, I will be responsible for a $75 missed appointment fee or a $50 late-cancellation fee, which will be invoiced accordingly.
ID Card (If client is a minor without an ID, use guardian ID card)

Cancelof
Insurance Card (Front)

Cancelof
Insurance Card (Back)

Cancelof
Signature
Should be Empty: