Daya Mental Health Appointment Request

Upon submission of our appointment request our staff will send our intake paperwork to your email. Please watch for this. Once our required intake paperwork is complete, we will call to schedule. Any forms that are not completed, will be deleted after 7 days and you will need to resubmit a new request form. Thank you.

Daya Mental Health and Wellness

77 Central Ave Suite A Asheville, NC 28801

828-412-3330

First Name

Last Name

Email address

Phone Number

Date of Birth

If you are on any medication, please list medication and doses

What current concerns/ conditions do you wish to request help for?

If so, where?

Provider preference

Insurance Company (We accept BCBS, Cigna, Aetna, United, several sister companies under United, Optum, UMR and TriCare

We do NOT accept Medicaid or Medicare Plans

Who referred you?

If no referral source- enter "self"

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