Appointment Request Form

Appointment Request Form

Let us know how we can help you! Please fill all the required fields (marked with *) before submitting your form
Appointment Type
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
What services are you interested in?
Insurance type
Your Insurance company
List of our accepted Insurances
Your Member ID Number
Effective July 30th, 2026, Psychiatry Associates of Wyoming and Des Moines requires all patients to pay a one-time, non-refundable administrative deposit of $75 at the time of their initial appointment or service request. This fee applies regardless of insurance coverage and is intended to support effective service delivery and engagement with our practice. Please note that this administrative deposit is non-reimbursable and will not be applied toward future services or billed to insurance companies.
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