Set Up Your Appointment

Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone*
What would you say are your biggest challenges today?

DepressionAnxietyGriefAddictionAnger ManagementPrenatal/Postpartum SupportGender IdentityADD/ADHDRelationship IssuesUnsureOther
Guardian's Name (if applicable)

First NameLast Name
Guardian's Phone Number (If Applicable)

Area CodePhone*
Mental Health Services Cannot Wait: If you are in a crisis situation, please call 988 or visit your local emergency room. *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.*

I Understand
When would you like your first 30 minute appointment with us?*

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
Mental Health Services Cannot Wait:

If you are in a crisis situation, please call 988 or visit your local emergency room.

*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.
*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.
Birth Date*

MonthDayYear
What days/times work best for you?
We'll do our best to match your preferred day/time!
What services are you most interested in?*

Couples CounselingAddiction TreatmentAnger Management ClassesPregnancy/Postpartum SupportFaith-Based CounselingAlternative to In-Patient TherapyIndividual TherapyTelehealthFamily CounselingMRT ParentingMRT Anger ManagementMRT Staying QuitMRT Escaping Your PrisonMRT Untangling RelationshipsTeen Group ProgramPsychiatryMedication ManagementTMS (Transcranial Magnetic Stimulation)IV Ketamine (not covered by insurance)Facial Therapy (not covered by insurance)Vitamin Therapy (not covered by insurance)UnsureOther
Mental Health Services Cannot Wait: If you are in a crisis situation, please call 988 or visit your local emergency room. 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.
What experience are you open to?*

I prefer to see someone in personI'm open to Telehealth optionsI'm open to either in person or telehealth
Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number
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.
Insurance Card

Please upload a photo of the front and back of your insurance card.
Cancelof
Policy Holder's Name:  First Name   Last Name
Policy Number:
Group Number:
Group Name:
SSN:   000-00-000
Existing Clients

I understand
Address

Street Address

Street Address Line 2

CityState

Zip Code
What can we help you with?

AnxietyADHDDepressionGriefCouples CounselingAddiction TreatmentAnger ManagementParenting ClassesMRT- Re-entryGender IssuesEating DisordersFaith-Based CounselingBehavioral IssuesOther
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