Appointment Request

If this is an emergency, call:

New Client Information - Appointment Request

First Name:

Last Name:

Are you a new or returning client?

New

Returning

Primary Phone Number

Email address

Date of Birth

Street Address

City

Zip Code

Member ID

As shown on insurance card

Phone Number for Provider Services / Behavioral Health or Mental Health

Typically found on the back of Insurance Card

Name of Primary Holder of this Policy:

Primary Policy Holder's Date of Birth:

Insurance Card Front and Back

Add file

Please upload a file

Driver's License or Picture ID

Add file

Please upload a file

Preferred session type?

In Person

Virtual / Telehealth

No Preference

Preferred Location

Dalton

Rome

Virtual / Telehealth

Do you have a preferred therapist in mind?

Please enter the name of your preferred therapist

Preferred Day of the Week and Preferred Time of the Day (AM/PM)

Briefly describe your reason for seeking therapy now? *This info will help us match you with a therapist.

Your information will be encrypted.