First Steps With Emerald Therapy Center!

1
When would you like your first 30 minute appointment with us?* This field is required.
Same-Day Telehealth (Request must be in by 1pm, Mon-Fri)
Same-Day in-person (Request must be in by 1pm, Mon-Fri)
Same Week
2
*Appointments are subject to scheduling availability for new client intakes.

In-Person appointments are available in Paducah, Murray, and Mayfield, Kentucky.

Telehealth Appointments are available across Kentucky.
3
Name* This field is required.
First Name
Last Name
4
Birth Date* This field is required.
Month
Day
Year
5
What would you say are your biggest challenges today?* This field is required.
Attention Span Issues
Depression
Grief
Addiction
Anger Management
Parenting Issues
Gender/Sexuality Issues
Eating Disorders
Behavioral Issues
Relationship Issues
Anxiety
Family Issues
Unsure
Other
6
What days/times work best for you?
We'll do our best to match your preferred day/time!
7
What services are you most interested in?* This field is required.
Couples Counseling
Addiction Treatment
Anger Management Classes
Pregnancy/Postpartum Support
Faith-Based Counseling
Alternative to In-Patient Therapy
Individual Therapy
Telehealth
Family Counseling
MRT Parenting
MRT Anger Management
MRT Staying Quit
MRT Escaping Your Prison
MRT Untangling Relationships
Teen Group Program
Psychiatry
Medication Management
TMS (Transcranial Magnetic Stimulation)
IV Ketamine (not covered by insurance)
Facial Therapy (not covered by insurance)
Vitamin Therapy (not covered by insurance)
Unsure
Other
8
Email* This field is required.
example@example.com
9
What experience are you open to?* This field is required.
I prefer to see someone in person
I'm open to Telehealth options
I'm open to either in person or telehealth
10
Phone Number* This field is required.By providing a mobile number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
Area Code
Phone Number -- By providing a mobile number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
11
Gender* This field is required.
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12
Guardian's Name (if applicable)(if applicable)
First Name
Last Name
13
Address* This field is required.Please use the address listed on the insurance card (if applicable)
Street Address
Street Address Line 2
City
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Tunisia
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14
Mental Health Services Cannot Wait: If you are in a crisis situation, please call 988 or visit your local emergency room.* This field is required.
I understand
15
Social Security NumberThis is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client or if you prefer to give this to us over the phone when we reach out to schedule your first appointment.
16
Who is your insurance carrier?
This is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client or if you prefer to give this to us over the phone when we reach out to schedule your first appointment.
17
Insurance CardPlease upload a copy of your insurance card front and back (if applicable).
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Please upload a photo of the front and back of your insurance card.
Cancelof
18
Policy Holder's Name:   First Name     Last Name
Policy Number:
Group Number:
Group Name:
SSN:    000-00-000
19
Existing ClientsIf you've met with someone at Emerald within the last 6 months, please call 270.534.5128 to schedule an appointment.
I understand
20
AddressPlease use the address listed on the insurance card (if applicable)
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
What can we help you with?
Anxiety
ADHD
Depression
Grief
Couples Counseling
Addiction Treatment
Anger Management
Parenting Classes
MRT- Re-entry
Gender Issues
Eating Disorders
Faith-Based Counseling
Autism Spectrum Disorder
Behavioral Issues
Other
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