WELCOME TO EVOLVE - Patient Interest Form
Thank you for your interest to join the EVOLVE Family. We are eager to assist you in aligning and evolving your mental health goals with your reality while meeting you where you are through Telehealth. Please complete our intake form and one of our team members will contact you shortly to schedule your appointment. If you have not heard back from one of our team members within 48 business hours(excluding weekends and holidays), please email us at support@myevolvecg.com.
Email
*
example@example.com
Which provider are you seeking an appointment with?
*
Terri Miller, Psychiatric-Mental Health Nurse Practitioner (Medication Management and ADHD Testing/Treatment)
Brittany Chandler, Owner, Psychiatric-Mental Health Nurse Practitioner (Medication Management, ADHD Testing/Treatment, Medical Marijuana Evaluation, Substance Use/Abuse Treatment)
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Which of the following most accurately describe(s) you?
Male
Female
Non-Binary
Transgender
Intersex
Other
Pronoun Preference?
He/Him/His
She/Her/Hers
They/Them/Theirs
Ze/Zir/Zirs
N/A
Social Security Number
Marital Status
Single
Partnered
Married
Legally Separated
Divorced
Widowed
If the patient is under the age of 18 years, please enter the Parent/Legal Guardian/Responsible Party Name, Date of Birth, Social Security Number and Phone Number
Please upload Current Drivers License or Identification Card (Front and Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other Phone Number(If applicable)
Email
example@example.com
How would you like to receive appointment reminders?
Text
Phone Call
Email
We do not accept any insurance and will not provide SuperBills. Please acknowledge your understanding of this policy below.
We cannot service you in our SELF PAY practice if you currently have MEDICAID and/or MEDICARE. Please acknowledge if you have MEDICAID and/or MEDICARE as an insurance below.
Referral Source
How did you hear about us?
Patient Referral
Psychology Today
Social Media
Other
Thank you for your responses. Someone will reach out to you within 48 hours(not including weekends or holidays) to identify the next steps. If you were unable to attach your identification card, please email support@myevolvecg.com. Also if you have not received any response within the 48 hours as mentioned above, please contact the office at (804)214-6460 or email support@myevolvecg.com
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