Book a medication management appointment with Amethyst Mental Health by filling out the entire form below!

Actually, I’m only looking for a talk therapist. CLICK HERE to fill out our therapist referral form!

We accept most major insurances. Self Pay: Initial Evaluation: $280 | Follow up: $150

This form is to be used for MEDICATION appointments. I will fill out the "therapist referral form" above if I am seeking a therapist only.

We are medication management providers at Amethyst. We can help you locate a therapist after meeting with you, but if you are looking for therapy only please do not fill out this form.

We do NOT accept Medicaid/Medicare, Bluecare, Wellcare, Wellpoint, TennCare, Aetna Medicare, BCBS Medicare Advantage, or United Healthcare Community plan Medicare, or EAP insurance programs. 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. We are not participants of their program, nor are we EAP participants!

What type of provider fits the patient's age?

Help us place you with the right provider

Are you looking for a specific provider?

Amber Kerby is not currently accepting new patients.

Please select what insurance plan you have or self pay.

IF WE ARE IN NETWORK WITH YOUR INSURANCE AND YOU WANT TO SELF PAY, YOU MUST DISCLOSE THIS TO US & SIGN A SELF PAY AGREEMENT OPTING OUT OF USING YOUR INSURANCE BENEFITS!

Patient's Name

Patient legal government name only

First Name

Last Name

Patient's Date of Birth:

Phone (Must be patient number if they are 18+)

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Who does the phone number belong to?

So we know who we are communicating with! (Self? Mom/Dad? Spouse? Case worker?)

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..?

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

Controlled Substance History

If you are moving to TN from out of state and are taking a controlled substance (stimulants/benzos/opiates), please list the state you received your last refill.

How did you find us!?

Please be specific!

If you selected therapist or another clinic/pcp/Dr., or OTHER please list their name specifically so we can thank them! :)

We offer psychiatric medication management services. We are not a crisis/rehab/detox center. Your appointment will be virtual until your provider tells you differently. DO NOT DRIVE to the mailing address found on our website!

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.

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.

Hands holding a purple amethyst geode against a blurred background. At Amethyst Mental Health & Wellness, LLC in Murfreesboro, TN, Middle Tennessee