Envision Healthcare Services, LLC
145 Highway 15-401 Bypass West Ste. 9
Bennettsville, Sc 29512
Office: 843-456-5045
Crisis: 843-267-5207
Fax: 843-258-5065
If you would like to schedule an Individual, Family, or Group Therapy Appointment, please review and complete the following form. One of our Administrators will follow-up with you.
Date Of Birth
-
Month
-
Day
Year
Date
PERSONAL INFORMATION (Required)
The information provided is for the individual receiving services:
Name
Last Name
First Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Please Select
Male
Female
Not willing to Disclose
Phone Number
Email
example@example.com
LOCATION (*Required)
Please enter your preferred service location:
Bennettsville
Sumter
Virtual
SCHEDULE (*Required)
Please choose your trip type, and the times and dates for pickup.
Individual Therapy
Family Therapy
Group Therapy
Preferred Date
-
Month
-
Day
Year
Date
Preferred Am or PM
AM
PM
INSURANCE INFORMATION (Required)
Please provide us other individual(s) to join you. This will allow us to accommodate you as well as others.
Insurance Information
Insurance Provider:
Insurance Number:
ADDITIONAL INDIVIDUALS (*Required)
Please provide us other individual(s) to join you. This will allow us to accommodate you as well as others.
Name
Relationship
Age
Name
Relationship
Age
Name
Relationship
Age
NOTES: If there are any special requirements and/or information we need, please let us know here.
SCHEDULE AN APPOINTMENT
Submit Form
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