Request an Appointment Please use this form to request an appointment. Kindly complete as accurately as possible. About YouPatient's Name(Required) First Middle Last Parent / Guardian's Name First Last Patient's Date of Birth(Required) MM slash DD slash YYYY I am a / an:(Required)Existing PatientNew PatientReturning PatientHow did you hear of us?(Required)Doctor's OfficeFriend or FamilyGoogle SearchInsurerOtherIf Other, please describe: Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How Can We Reach You?We would love to chat with you. How can we get in touch?Preferred Method of Contact(Required)EmailPhoneYour Email Address(Required) Email Address Confirm Email Address Phone Number(Required)Alternate Phone NumberYour InsuranceHave there been any changes to your insurance since your last appointment?(Required)YesNoUnsureI am uninsuredInsurer(Required)AetnaBlue Cross Blue ShieldMedicareOptumUnited HealthViva HealthOtherOther Insurer Policy Number Expiry Date MM slash DD slash YYYY Your Mental Health NeedsTell us about your experience so we can best assist you.What Service are you seeking?(Required) Psychiatry Counseling Psychiatry & Counseling I am unsure and would like to speak with someone Select AllPlease select all that apply.Your experience with mental health care(Required) I am currently working / have worked with a psychiatrist I am currently working / have worked with a psychologist I am currently working / have worked with a therapist I am unsure if I have worked with mental health professionals I have not worked with any mental health professionals Please select all that applyYour MedicationsTell us about your current medication, if any.Select what best describes you(Required) I am currently taking prescription medications I am currently taking prescription medications and require a refill I am currently not taking any prescription medications Your AvailabilityPlease select 3 different times and days that suit your schedule. We shall try our best to accommodate you.Time(Required)Mondays AMMondays PMTuesdays AMTuesdays PMWednesdays AMWednesdays PMThursdays AMThursdays PMFridays AMFridays PMNo preferenceTime(Required)Mondays AMMondays PMTuesdays AMTuesdays PMWednesdays AMWednesdays PMThursdays AMThursdays PMFridays AMFridays PMNo preferenceTime(Required)Mondays AMMondays PMTuesdays AMTuesdays PMWednesdays AMWednesdays PMThursdays AMThursdays PMFridays AMFridays PMNo preferenceOther Questions or Comments(Required)AcknowledgmentsBy selecting the above checkboxes, I acknowledge these terms and conditions and provide consent to transmission of the form. I understand information submitted may be sent through release Alabama Psychiatry and Counseling and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the form or the transmission thereof.I understand:(Required) Completion of this form is to make an appointment request only and I will be contacted by Care Team to confirm my appointment It may take up to 3 business days for my appointment request to be processed Requests received after 5:00pm on weekdays, over weekends or holidays will be processed on the next business day If I require immediate attention, I willI email [email protected] Select All
