Test Contact Form Please enable JavaScript in your browser to complete this form.First Name *Last Name *Email *PhoneSMS ConfirmationI agree to be contacted by SMS/text.TypeI am…New patientExisting patientPhysicianOtherPatient nameServicesMedicationTestingTherapyTMSSpravatoPre-surgical evaluationForensics evaluationIntensive outpatient services (PHP/IOP)Payment optionsChoose your insurance typePrivate insurance (via your employer)MedicareTenncareNo insurance (self pay)InsuranceYour insuranceAetnaBCBSCignaTricareUnitedOtherDate of birthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Member IDInsurance card Click or drag files to this area to upload.You can upload up to 2 files. Optionally uploads photos of the front and back of your insurance card.Out-of-Pocket OptionAre you able to pay out-of-pocket if we are unable to accept your insurance?Preferred pronounsMy preferred pronouns…He/himShe/herThey/themPreferred contact methodI prefer to be contacted…EmailSMSPhoneLocationMy preferred office…ClarksvilleFranklinHendersonvilleKnoxvilleMemphisMurfreesboroNashvilleParagraph TextWe’re sorry Unfortunately, we cannot accept TennCare at this time. We suggest you contact the Mental Health Cooperative or calling them at 866-816-0433Send
