New Patient Appointment Form

New Patient Appointment Request

If you are experiencing a mental health emergency or crisis, stop and call 911, the crisis line at 988, or go to the nearest emergency department.
Thank you for considering Ground Up Behavioral Health. We’re honored by your interest in scheduling an appointment. To help us understand how we can best support your mental health needs, please complete the form below.
Are you the patient or the parent/legal guardian?
- Patient's Legal Name
  
  First NameLast Name
- Preferred Name
- Date of Birth
  
  DayMonthYear
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email
- What is your primary reason for seeking care?
  Please include any current mental health concerns, symptoms, or recent stressors you'd like us to be aware of.
- What medication(s) are you currently taking?
  Please include dose and frequency. Type "None" if you are not taking any medications currently.
- We may prescribe stimulant medications such as Adderall, or controlled substances like Klonopin, Ativan, Valium, or Xanax, only under very strict criteria and when clinically justified. These medications are used rarely and with great caution.
- What insurance do you have?
  
  Other
- Out-of-network plans are eligible for reimbursement and we can provide a superbill/detailed receipt. We understand that there are specific subsidiary plans under the insurance carriers listed below that are not included here. Call us at 334.746.5586 or contact us here to see if we accept your insurance.
- What's your insurance member ID?
  Type "NA" if you don't have insurance
- What's your insurance group number?
  Type "NA" if you don't have insurance
- Please provide the primary subscriber's full name, your relationship to the subscriber, and date of birth if you are not the primary subscriber.
  
  Primary Subscriber's Full NameYour Relationship to the Primary SubscriberPrimary Subscriber’s Date of Birth
- Please upload a copy of the front and back of your insurance card.
  
  Cancelof
- Parent or Legal Guardian's Name
  
  First NameLast Name
- Relationship to Patient
  Parents/Legal Guardians, please be advised that the legal age of consent in Alabama is 14. We require consent for treatment from the patient themselves if they are 14 or older and any information regarding their care cannot be released to you without their permission.
- Patient's Legal Name
  
  First NameLast Name
- Preferred Name
- Date of Birth
  
  DayMonthYear
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email
- What is your primary reason for seeking care?
  Please include any current mental health concerns, symptoms, or recent stressors you'd like us to be aware of.
- What medication(s) are you currently taking?
  Please include dose and frequency. Type "None" if you are not taking any medications currently.
- We may prescribe stimulant medications such as Adderall, or controlled substances like Klonopin, Ativan, Valium, or Xanax, only under very strict criteria and when clinically justified. These medications are used rarely and with great caution.
- What insurance do you have?
  
  Other
- Out-of-network plans are eligible for reimbursement and we can provide a superbill/detailed receipt. We understand that there are specific subsidiary plans under the insurance carriers listed below that are not included here. Call us at 334.746.5586 or contact us here to see if we accept your insurance.
- What's your insurance member ID?
  Type "NA" if you don't have insurance
- What's your insurance group number?
  Type "NA" if you don't have insurance
- Please provide the primary subscriber's full name, your relationship to the subscriber, and date of birth if you are not the primary subscriber.
  
  Primary Subscriber's Full NameYour Relationship to the Primary SubscriberPrimary Subscriber's Date of birth
- Please upload a copy of the front and back of your insurance card.
  
  Cancelof
- Should be Empty:

New Patient Appointment Request