new patient

First Name

Last Name

Date of Birth

Month

Day

Year

Cell Phone Number

Gender

How'd you hear about us?

Communication Preference

Contact By Email Contact By Text

Home Address

City

State

Zip

Insurance Verification is completed the day prior to the appointment. If no insurance is provided before your appointment, you will be considered self-pay. The rate is $250 for an initial evaluation and $90 for follow-up appointments.

Name of Insurance Company (N/A if Not Applicable)

Member ID (N/A if Not Applicable)

Group ID (N/A if Not Applicable)

Check Below to Confirm you are a New Patient and will be completing the Psychiatric Evaluation online through Telepsychiatry.
New Patient (Initial Evaluation)

new patient

Communication Preference

You can also contact us Monday thru Friday 9 am – 5 pm at 305-740-3340.