Appointment Request Form

Appointment Request Form

Let us know how we can help you!
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Age Range*
How do you plan to pay for services*

InauranceSelf Pay
We accept the following insurances, please select your insurance carrier(s)

Aetna/Aetna Better HealthAnthem/BCBS(Medicaid/Medicare and Commercial Plans)Cigna(Virginia Plans only)MedicaidMedicareNHPRISentara Health PlansTufts/Harvard Pilgrim HealthUnited Healtcare(Commerical Plans Only)
Referral Source*
What are you looking to get help with?*

Medication ManagementTalk TherapySpravato ConsultMedical Marijuana Consult
Are you currently taking medications for your mental health?*

YesNo
What time of day is best for you?*

MorningsAfternoonsFlexible
Terms & Conditions – Appointment Request

By submitting this form, you acknowledge and agree that:
- This form is for appointment requests only and does not establish a provider–patient relationship.
- Required medical, insurance, and identification information will be collected securely through our patient portal after scheduling.
- You authorize Eccentric Minds Health & Wellness PLLC to contact you by phone, email, or text regarding scheduling and next steps.
- If submitted for a minor, a parent or legal guardian must participate in scheduling and complete required consent forms.
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