New Patient Form

New Patient Scheduling Tool

HIPAA compliant*
We are honored you are allowing us to become part of your healthcare. To expedite scheduling of your first intake appointment, please complete the following brief questionnaire and upload a picture of the front and back of your insurance card, then press submit. (You can use your cell phone to take the picture of each side.)

Once we verify your insurance, our scheduling team will contact you as soon as possible during normal business hours to present options for scheduling your appointment. This is a quick process and you will be hearing from them soon.

Any questions? Give us a call at 423-430-9681.

*We are still finalizing the credentialing process with a few insurance payors. If you have Aetna or Humana, please call the office prior to scheduling. Updates are happening daily, and all should be in place soon.

*Our scheduling tool is under construction today, but this will not delay your process!
Quick Safety Check: Are you currently experiencing any of the following urgent situations?
- Active suicidal intent or plan
- Recent suicide attempt
- Acute psychosis with safety concerns
- Severe substance/alcohol withdrawal risk
*IF YES TO ANY, YOU REQUIRE EMERGENT CRISIS EVALUATION AND SHOULD NOT WAIT FOR OUTPATIENT SCHEDULING. PLEASE CLICK ON THE 24/7 CRISIS LINKS BELOW AND DO NOT SUBMIT THIS FORM AT THIS TIME.

Local 24/7 crisis resources in the Tri-Cities region include:
988 - Suicide & Crisis Lifeline (call or text 988)

Ballad Health Crisis Services - Woodridge (Johnson City)

Creekside Behavioral Health (Kingsport)

Frontier Health Turning Point Crisis Stabilization Unit

Mobile Crisis Hotline (Frontier Health)

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Which physician would you prefer to schedule with? *
Please provide your name.*

First NameLast Name
MaleFemaleOtherChoose not to disclose
Date of birth*

MonthDayYear
Date
Mobile Number*
(We will contact you with scheduling options within 1 business day)Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Info*
Member ID (if self-pay, type n/a)*
Please attach a photo of the FRONT side of the your insurance card.

Select Insurance Card Image

Cancelof
Please attach a photo of the BACK side of your insurance card.

Select Insurance Card Image

Cancelof
I just want to clarify my diagnosisEstablish as a new patientTreatment-Resistant psychiatric symptomsADHD Evaluation and/or TreatmentBipolar Spectrum EvaluationTrauma-Related ConditionsAll Other
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New Patient Scheduling Tool