New Patient Appointment Request Form

Where do you live?*

TennesseeFloridaVirginiaKentuckyOregonConnecticut - coming soon!
Prefer to call or text?

We’re here 24/7 at (615) 478-6748.
Upload your ID and insurance card via text link within 4 hours.

If we don’t receive them in time, we’ll need to cancel and reopen the slot 🧡.
Full Name*

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address*
example@example.com
We are required to verify your identity. Please upload a copy of your Driver's License or ID card.*

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Please include a copy of your insurance card. (Front and Back)

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Address

Street Address

Street Address

CityTN, FL, VA, KY, OR only

Zip Code
Select the specialist you would like to work with:

Lynn Wolf - TN, VA, ORKerrie Wilder - TN, FLLaura Pohl - TN, FL, KYStephanie Hubbell - TN, VA, FL, KY, ORNext Available Specialist
Date of Birth

YearMonthDay
Do you agree to receive text messages and emails from us?*

YesNo
Gender*

FemaleMale
How did you hear about us?

GooglePsychology TodayInsurance Company DirectorySocial Media (Facebook, LinkedIn, Instagram, Twitter)Advertisement (Brochure)OtherReferred by friend or professional. (Please share their name in the text box so we can thank them.)
Do you understand that all appointments at our practice are conducted VIRTUALLY? (We do not offer in-person appointments.)
How can we support you? Tell us about the challenges you're facing or your goals for seeking care. Share any details you think will help us personalize your mental health journey.

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Choose How We Should Bill for Care

We've designed flexible choices to support your wellness journey.
Click to decide what fits your needs*

Insurance - Copays and deductibles apply.Self-Pay - $245 for the first visit and $135 for follow-up visits.
You have selected to use your insurance coverage. Please agree to the following:*

I understand it is my responsibility to contact my insurance company to verify coverage for WMHS services. If telehealth mental health services are not covered, I agree to be responsible for the payment of services.
Which company are you insured with?*

AetnaCignaBCBSTricareWe DO NOT accept Medicaid or Medicare.We DO NOT accepting new UHC/Optum, at this time.We DO NOT accept Florida Blue HMO and some other HMO plans.
For more information and alternative solutions, please refer to our Insurance FAQs.
SPONSORS DATE OF BIRTH*

YearMonthDay
Date
Member ID #: *
Please add your insurance Member ID #.
Group #: *
Please add the Group #.
Are you the policy holder?*

YesNo
Full Name of the Policy Holder:*
Policy Holder Date of Birth:

YearMonthDay
Date
Relationship to the Policyholder:

SelfSpouseChildOther
Do you have secondary insurance policy?*

YesNo
Member ID #:*
Group #:*
Please include a copy of your secondary insurance card. (Front and Back)

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Next, you’ll schedule your appointment.

No need to re-enter insurance details - just select “No Insurance” (you already entered it!).

Choose your service:
→ For mental health care: Behavioral Health – Telehealth
→ For hormone & metabolic care: Specialized Exam

Reason for visit - Required | What reason should I choose?

Watch for a Message from Your Account Specialist
We’ll reach out via Spruce to help you complete setup. Here’s what to expect:

For Insurance Patients:
✔️ Confirm your connection to Spruce and Athena Patient Portal
✔️ Complete insurance verification
✔️ Review any copay, deductible, or out-of-pocket costs
✔️ Add your payment or HSA card to Athena

For Self-Pay or Subscription Patients:
✔️ Confirm your connection to Spruce and Athena Patient Portal
✔️ Complete your self-pay or subscription agreement
✔️ Add your payment or HSA card to Athena
✔️ Prepay for your first visit or first subscription payment
✔️ Authorize card-on-file use and confirm monthly billing

Final Confirmation
Once payment and verification are complete, we’ll finalize your appointment and you’re officially set!

📲 Important:
You’ll receive a text invite to Spruce - please allow notifications so we can stay connected and support you.

⏳ Note: All appointment requests stay pending until payment and verification are completed.
Should be Empty:

Choose How We Should Bill for Care