Request an Appointment

Thank you for your interest in our practice! Please be aware that we are out of network with insurance, but can provide superbills if requested. We will contact you to schedule your appointment within 72 business hours.

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Emergency Assistance

If this is an emergency, please call 911 or present to your nearest emergency room. Do not use this form for crises or emergencies. We will respond to your request within 48 hours.

Suicide Hotline: 800.273.8255
Tennessee Crisis Line: 855.274.7471

Name (First and Last)

Date of Birth

Email address

Phone number

Street Address

City

Zip Code

Can we leave you a voicemail?

Yes No

Can we send you a text message?

Yes No

Preferred visit type:

In Person Virtual First Available

How would you prefer to schedule your appointment?

Text Message Phone Call No Preference

Schedule your phone call with our administrative staff by clicking here

How did you hear about us?

If you were referred by another clinician, please include their full name and/or the name of the organization they are with.

Reason for Visit:

By checking this box, I acknowledge that I understand that Empowered Heart Integrative Mental Health Care does not accept insurance and that I have reviewed the service fees on their website (https://www.empowered-heart.com/services).

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Emergency Assistance

If this is an emergency, please call 911 or present to your nearest emergency room. Do not use this form for crises or emergencies. We will respond to your request within 48 hours.

Suicide Hotline: 800.273.8255
Tennessee Crisis Line: 855.274.7471

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