new patient contact request

This request form is for new patients only.

If you are a current patient, please call the office at 478-745-9206.

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Name *

First

Last

Make sure to include your name as it appears on your insurance card or license.

you or What

InsuranceAnthem / BCBSCignaMedicareOtherCash

Include your insurance info so we’re ready when we follow up with you.

Email *

What services are you interested in?

• Psychiatric Medical Care
• Therapy
• Independent Medical Examination
• Medication Management
• Spravato
• Other

Are these services for you or another person? *

• Myself
• Someone Else

Please note, we can only make appointments for individuals contacting us on their own behalf.

Submit