Psych Atlanta New Patient Request
If this is an emergency or you feel you are in danger please call 911.
Full Government Name
*
First Name
Last Name
Date of Birth:
Preferred Name
First Name
Last Name
Preferred Pronouns:
Preferred Location:
Please Select
Marietta
Roswell
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Type of Appointment:
*
TRD (Treatment Resistant Depression)
Research Study
Medication Management
Other
For TRD (Treatment Resistant Depression):
IV Ketamine
Spravato (Nasal Esketamine)
TMS (Trans-Cranial Magnetic Treatement)
Primary Reason for Appointment:
*
Current Psychiatric Medications:
How did you hear about us?
*
Please Select
Online
Doctor Referral
Friend
Family Member
Other
Please Specify
Recent Psychiatric Hospitalization?
*
Please Select
Yes
No
Please Specify When:
Method of Payment:
Please Select
Insurance
Self Pay
Insurance Company:
Insurance Cards
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ID Card (Driver's License or Other)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Interested in Our Research Studies?
Please Select
Yes
No
Not Sure/I Want More Information
Psych Atlanta does NOT provide services for patients that are seeking a one time court ordered appointment, Workers Compensation cases, FMLA/Disability Forms ONLY, or patients seeking service animal forms ONLY.
Psych Atlanta providers do not fill out any forms until you have been established for at LEAST 6 months.
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