Patient Information
Patient Name
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
State
*
Please Select
Alabama
South Carolina
North Carolina
Front of Identification Card
*
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Please upload a Government Issued ID to help verify Identity
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Back of Identification Card
*
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Please upload a Government Issued ID to help verify Identity
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Insurance Information
Subscriber Name
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Insurance Plan or Program Name (e.g., Cigna, Blue Cross, United Health Care) OR "Self-Pay"
If UNINSURED enter "Self-Pay" to discuss estimated self-pay rates. This information can help speed up scheduling.
Subscriber Relationship to Patient
Please Select
Self
Spouse
Parent/Guardian
Other
Member Policy #
Group #
Front of Insurance Card
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Please upload the FRONT of your insurance card.
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Back of Insurance Card
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Please upload the BACK of your insurance card.
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Appointment Request Information
What type of services are you requesting?
Psychiatric Evaluation
Pharmacotherapy / Medication Management
Depression and/or Anxiety Treatment
Other or Not Sure Yet
Reason for Appointment Request
Current Medications
How did you hear about us?
Please Select
Online Ad
YouTube Ad
Radio
Direct Referral
Doctor's office
Psychology Today
Other
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