Grata Appointment Request Form
Welcome to Grata
We have same-week appointments available for new patients. Fill this fully-encrypted, HIPAA-compliant form to get started!
Who are you filling this form for?
*
Please Select
For Myself
For Someone Else
Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Sex (as listed on insurance policy)
*
Please Select
Male
Female
Email
*
We'll send the appointment info to this email.
Phone
*
Format: (000) 000-0000.
Address
*
Line 1
Line 2
City
State
Zip Code
What substance(s) do you need help with?
*
Alcohol
Opioids
Tobacco
Cannabis
Other
Are you currently using benzodiazepines (like Xanax, Ativan, Valium)?
*
Yes
No
Are you thinking about hurting yourself or someone else today?
*
Yes
No
Are you currently pregnant?
*
Yes
No
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Insurance Info
Primary payment method
*
Insurance (Medicaid, United, Cigna, Aetna, Blue, etc)
Cash (Out of Pocket)
Insurance Plan Name
*
Please Select
Aetna
Blue Cross Blue Shield
Evernorth (Cigna)
Medicaid
Optum
United
Other
Other Plan Name
*
Insurance Policy Number
*
Is the individual receiving services the primary subscriber of this plan?
*
Yes
No
What is the name of the primary subscriber of this plan?
*
First Name
Middle Name
Last Name
[Optional] Please upload the front of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Availability
When are you available for weekly appointments? Please select as many times as possible. (CDT)
*
Rows
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
7 - 8 am
8 - 9 am
9 - 10 am
10 - 11 am
11 am - 12 pm
12 - 1 pm
1 - 2 pm
2 - 3 pm
3 - 4 pm
4 - 5 pm
5 - 6 pm
When can we call you for a few minutes today or tomorrow to schedule your appointment?
*
Do you consent to receiving SMS from Grata Health so we can communicate with you?
*
Yes
No
Do you consent to receiving emails from Grata Health so we can communicate with you?
*
Yes
No
If you were referred to Grata, who referred you?
How did you hear about Grata?
*
Please Select
Google Search/Ad
Facebook/Instagram Ad
Friend or Family
Doctor
Emergency Room
Court/Jail Referral
Food/Housing Shelter
Reddit
Other
Please specify how you heard about Grata
Anything else we should know about you or your availability?
Submit
Should be Empty: