Do not use this form for emergencies. If this is an emergency call 911. All inquires will receive a response within 1 business day.

New Client Appointment Form

**For new clients fill out the form

Current clients who would like to reschedule can contact the office by calling:

(423) 430-9687 or by going to the online patient portal.

Full Name *

Date of birth *

Insurance Carrier *

Note: due to insurance restrictions, not all providers are in-network with carriers.

If you chose "Other" above, please indicate your insurance carrier here:

Phone Number *

Email Address *

City *

State *

Zip *

How would you like to receive services? *

Interested in: *

When are you available for therapy sessions? *

Which therapist would you prefer? *

I need help with: *

How did you hear about us? *

New appointment requests are INCOMPLETE until finalized with a support specialist by phone. A member of our admin team will reach out to finalize your appointment, please have your health insurance card and credit card information available.

24-Hour Cancellation Policy: Appointments can be canceled/rescheduled if 24 hours notice is provided. If less than 24 hours is given, the full amount of the session will be charged to the payment method on file. In order to be our client, you must agree to this policy. By scheduling an appointment, you hereby agree to this policy.