New Patient Appointment Request Form
States We Serve
Currently we are providing care in Tennessee, Florida, Kentucky, and Virginia.
From this point on, you won't walk alone.
We'll offer you support every step of the way to get you to your initial appointment and well on your way to the care you deserve.
Full Name
*
First Name
Last Name
Date of Birth
*
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Year
-
Month
Day
Address
*
Street Address
Street Address
City
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 (We can currently see patients in: TN, FL, KY, and VA.)
Zip Code
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Do you agree to receive text messages from us?
Yes
No
Gender
Female
Male
How did you hear about us?
Google
Psychology Today
Referred by friend or professional - please add name to Other below
Insurance Company Directory
Social Media (Facebook, LinkedIn, Instagram, Twitter)
Transferring from Diana Health
Other
If you are transferring from Diana Health, when did your provider want to schedule your follow-up appointment?
Date or Length of Time for Follow-Up
Do you understand that all appointments at our practice are conducted VIRTUALLY? (We do not offer in-person appointments.)
*
Yes, I understand and agree.
No, I need more information about this.
Please upload a copy of your Drivers License or ID card.
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We are thrilled you found us!
Our mission is to revolutionize the way women access and receive expert WOMAN-FOCUSED care. We’re here to make that happen for you!
Kerri Wilder, CNM, PMHNP
Welcoming new patients in TENNESSEE & FLORIDA, including those who are self-pay or covered by Aetna, Cigna, UHC/Optum, and BCBS insurance plans.
Kerrie specializes in mood disorders, perinatal support, personality struggles, and sexual satisfaction, offering personalized and empathetic care. "My goal is to help you feel your best in all areas of your life! Whether you have faced mental health challenges before or are seeking support for the first time, I bring firsthand experience and knowledge of various options—from complex medication management to therapy. Together, we can bridge the gap between mental and physical healthcare."
Kerrie Wilder, CNM, PMHNP
Laura Pohl, CNM, PMHNP
Welcoming new patients in FLORIDA & TENNESSEE who are self-pay or covered by BCBS, Aetna, Cigna, UHC/Optum, OR Tricare.
Laura is a dedicated specialist in perinatal mental health, mood disorders, ADHD, and the various challenges that come with womanhood and motherhood. With her expertise and compassionate approach, Laura is here to provide the support you need.
Lynn Wolf, CNM, PMHNP
Welcoming new patients in TENNESSEE & VIRGINIA who are self-pay or covered by BCBS, Aetna, Cigna, and UHC/Optum insurance plans.
Lynn excels at building strong therapeutic relationships that foster healing and support. "My goal is to help you realize that you are not alone in this journey, and my therapeutic style is meeting you where you are. I am non-judgmental, caring, and empathetic."
Lynn Wolf, CNM, PMHNP
Provider Request:
Next Available Provider
Lynn Wolf, CNM, PMHNP - Lynn will be accepting new patients residing in Virginia, Tennessee, and Florida starting August 1.
Kerrie Wilder, CNM, PMHNP - Next New Patient Appointment available within 1 week. Kerrie is currently accepting new patients residing in Tennessee and Florida.
Laura Pohl, CNM, PMHNP- Next New Patient Appointment available within 1-2 weeks. Accepting new patients residing in Tennessee and Florida.
Stephanie Hubbell, CNM, PMHNP - Next New Patient appointments within 2 weeks. Accepting new patients residing in Tennessee, Florida and Kentucky.
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How will you pay for your visit?
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Insurance
Self Pay
Other
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New Patient Appointment
Self Pay Rate
$
245.00
Quantity
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Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
If you are using insurance, which company are you insured with?
*
Aetna
Cigna
UHC or Optum
BCBS
Tricare
NONE OF THE ABOVE
SPONSORS DATE OF BIRTH
*
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Year
-
Month
Day
Date
Member ID #
*
Please add your insurance Member ID #.
Group Number
*
Please add the Group #.
Please include a copy of your insurance card. (Front and Back)
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Are you the policy holder? If no, complete the next section.
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No
Full Name of the Policy Holder:
Policy Holder Date of Birth:
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Year
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Month
Day
Date
Relationship to the Policyholder::
Spouse
Child
Other
Do you have secondary insurance policy?
Yes
No
Member ID #
*
Group Number
*
Please include a copy of your secondary insurance card. (Front and Back)
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How can we help? Please include any details you believe will help us begin your mental health journey.
This is where you tell us about why you are seeking care!
Your well-being is our top priority!
Complete your intake forms right away for the fastest access to expert and compassionate mental health support.
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