If you are experiencing a medical or psychiatric emergency, please dial 9-1-1 or go to your nearest emergency room.National Suicide Hotline: 1-800-273-8255TN Crisis Hotline: 901- 577-9400 Interested in Becoming a New Patient? Please note: Request does not guarantee approval as some clients will not qualify for services or will require a higher level of care. Complete the form below to request a new patient appointment. Provider Preference * First Available Mandy Yount, PMHNP-BC (Adult & Children) - NOT IN NETWORK WITH TNCARE Victoria Carroll, PMHNP-BC ( NOT CURRENTLY ACCEPTING NEW PATIENTS) Amanda Eaves, PMHNP-BC (Adult only) Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Biological Male Biological Female Transgender Male Transgender Female Non-Binary Other Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Carrier * Aetna / Meritain Ambetter BHSG / MedBen Blue Cross Blue Shield of ARKANSAS Blue Cross Blue Shield (NOT BLUECARE) Cigna Mississippi Medicaid Private Pay ($295 Initial / $200 Follow-Up) Standard Medicare TennCare - Amerigroup/Wellpoint Only UnitedHealth Care / Optum (NOT MEDICAID) Group Number * Policy Number * ALL Current Medications * ALL Previous Medications * What brings you here today and what symptoms are you struggling with? * Name of Therapist Substance Use History (check all that apply) * Amphetamines / Speed / Meth Barbiturates / Downers Opiates / Pain Medications Cocaine Cannabis / Marijuana Tobacco Vaping Alcohol Benzodiazepines (Xanax, etc) Psychedelics (LSD, Ecstasy, Bath Salts) NO SUBSTANCE USE HISTORY Date of Last Use: * Have you been on Suboxone / Methadone treatment within the past year? * Please note: We are required to check prescription history. You must be off of Suboxone / Methadone for 12 months in order to schedule an appointment. No Yes Who Referred You To Us? * Important Information - PLEASE READ: I understand that I must attend the first appointment in-person. * Yes No I understand that I must be a resident of Tennessee or Mississippi to receive telehealth services. * Yes No I understand that I am required to keep a credit or debit card on file in order to schedule or receive services. * This applies to Medicare / Medicaid also. Unfortunately, you will not be scheduled without a form of payment on-file. Yes No I understand that I am required to pay my co-payment at the time of scheduling and that my co-payment is nonrefundable if I do not attend my appointment. * Yes No I understand that I must complete my medical history forms and consent for treatment within 48 of receiving the link. * NO YES I understand that any appointment requests made after 4pm on Thursday will be processed the following Monday, when the office reopens. The clinic is closed on Fridays. * Yes No (REQUIRED) Please send a copy of your Driver's License and Insurance Card to: EMAIL: DPS@901DPS.com (secure) OR TEXT: 901-296-3000 (secure) **** Optionally, you may choose to upload these documents during the time you are completing your medical history. Insurance cannot be verified and appointments cannot be scheduled without this information.
