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

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 Laurie Miller, APN or Jacqueline Sharp, PMHNP. Please note that Whitney Erickson, PMHNP and Lisa Williams, APN 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

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. If you do not provide current information, you are responsible for payment for services rendered. We are not in network with any Medicare policies, Tenncare, Aetna, or Tricare.

Insurance Company

If you do not have insurance, please type none.

Member ID

Group ID

Insured's name

Date of Birth

Relation to patient

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.