New Patient Appointment Request

By completing this form, I confirm that I am NOT in an emergency situation, not suicidal and not in a state of danger to myself or others.

If you or someone you know is suicidal, get help immediately via 911 or the nearest emergency room, the Suicide and Crisis Lifeline by calling or texting 988 or the Crisis Text Line by texting “HOME” to 741741.

Please note that requests are NOT monitored after business hours or on weekends.

Full name

Date of birth

Age

If you are completing this form for a minor, please provide your name and relation.

Address

Zip Code

Email address

Phone Number

I am requesting a new appointment for:

Medication management

With PMHNPs: Melissa Hardy, Justin McAdoo, Laurie Miller, Jacqueline Sharp, Whitney Trotter, or Natalie Ragland. Please note that Whitney Erickson and Lisa Williams are not accepting new patients at this time.

Therapy

With Beth Grant, MS, LPC, MHSP

Unsure

We will try to match you with the most appropriate provider based on the info you provide below.

Please provide a brief description as to why you are interested in our services.

Preferred date and time

Based on availability. We are closed on nights and weekends.

Kindly inform us who referred you

If your loved one is already connecting with a provider in the clinic, please note above.

Have you been or are you currently being treated by another provider for mental health? If yes, who?

This may be another psychiatrist, therapist, OBGYN, primary care physician, or pediatrician.

Are you involved in litigation or worker's comp? Are you needing FMLA or disability paperwork completed?

While we are still happy to see you, we ask this because we do not complete paperwork or take patients off work. If this is needed, we would refer you to a higher level of care.

Additional Comments/Questions

Provide insurance information below. We are not in network with any Medicare policies, Tenncare, Aetna, or Tricare. Please let us know in the below field if you do have one of these insurance.

Do you have any form of Medicare, Tenncare, Aetna, or Tricare insurance policy that is primary or secondary?

Yes No

Insurance Company

If you do not have insurance, please type none.

Member ID

Insured's Employer

Group ID

Insured's name

Date of Birth

Relation to patient

In order to assure we are in network with your insurance, please include a photo of the front and back of your insurance card.

Add file

Please upload a file

I understand that sending multiple requests, including using multiple methods of contact, will delay the office's ability to get back with me.

Your information will be encrypted.