Please fill out this brief survey and someone from our team will contact you within 48 business hours!

We accept most major insurances. Self Pay: Initial Evaluation: $260 | Follow up: $130

If you would like help finding a therapist only, please fill out our therapist referral form here!

What type of provider fits the patient's age?

Help us place you with the right provider

Please select what insurance plan you have or self pay.

This will let me know if I need to bother you with collecting insurance details!

Name

Please list the patient's name if minor child (not parent name).

First Name

Last Name

Date of Birth:

Phone

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Reason for appointment request:

Current Medications?

Please list all current prescriptions for our provider to review! Put "none" if you don't take anything.

Please list all previous psychiatric diagnoses

List if you have ever been treated for depression, anxiety, ptsd, schizophrenia, substance use, suicidal thinking, etc..?

Are you pregnant or planning to be?

Have you ever been hospitalized (stayed for longer than 2 days) in a mental health hospital/psych ward? If yes, when was your most recent hospitalization?

Put N/A if you answered NO

We offer psychiatric medication management services + plus holistic wellness coordinations. We are not a crisis/emergency/detox/MAT center.

If you are having a mental health crisis (active suicidal thoughts/plans, auditory and/or visual hallucinations, detoxing/withdrawing from substances): please call 911, go to your nearest ER, or find the ER/Crisis Resources menu and go to one of the options listed there.

Your appointment will be virtual until your provider tells you differently. DO NOT DRIVE to the mailing address found on our website!

We do NOT accept TennCare, Aetna Medicare, BCBS Medicare Advantage, or United Healthcare Community plan Medicare. If you have these plans you can NOT self pay for our services.

These plans are Medicare replacement plans that require the patient to be seen by a participating provider.

By submitting this form, you are providing consent for the submission of this form to a HIPAA compliant secured email storage, understand this website host does not store personal information, and Amethyst Mental Health & Wellness, LLC to access and review your medication history as part of our commitment to delivering personalized and comprehensive mental health care.

This information will be used solely for the purpose of enhancing our understanding of your unique needs and tailoring our services to best support you.

Do you need a translator for any language other than fluent English?

We do not offer emergency services. For emergent needs, please contact 911, your local emergency room, or the national suicide hotline at 1-800-273-8255