Schedule An Appointment
Enter your details to receive a call back from us.
Full Name
*
First Name
Last Name
Date of Birth
*
Ex: mm/dd/yyyy
Gender
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Please Select
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Email Address
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Provider [if you plan to pay direct rate, please put none]
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Insurance ID and Group Number [if you plan to pay direct rate, please put none]
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Are you the primary subscriber?
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Please Select
Yes
No
Not applicable
If not, who is?
Include Name, DOB and Relationship to Patient
Service Preference
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Please Select
In-Person (individual)
Telehealth (individual)
In-Person (couples or family)
Telehealth (couples or family)
Group Therapy Preference (If Applicable)?
Please Select
Emotion Regulation Group
Veteran Support Group
Which location would you prefer?
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Please Select
Clarksville, TN: 93 Beaumont St, Clarksville, TN 37040
Nashville, TN: 406 Royal Parkway, Nashville, TN 37214
Telehealth
Do you have a preferred therapist?
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Please Select
Yes
No
If yes, who would you like to see?
What time do you prefer?
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Please Select
8:00am - 9:00am
9:00am - 10:00am
10:00am - 11:00am
11:00am - 12:00pm
12:00pm - 1:00pm
1:00pm - 2:00pm
2:00pm - 3:00pm
3:00pm - 4:00pm
4:00pm - 5:00pm
5:00pm - 6:00pm
6:00pm - 7:00pm
7:00pm - 8:00pm
What days of the week do you prefer? (Select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I give permission to be contacted by the following methods:
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Phone
Email
How did you hear about us?
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Google
Facebook
Instagram
X (fka Twitter)
LinkedIn
Word of Mouth
In-Person
Other
Please verify that you are human.
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