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Become A Patient

Become A Patient

Please submit your information below and our team will review your application and contact you with next steps.

Please note: New patients must be 18 years or older.

New Patient Application

Will you need any language interpretation services? *

Yes

No

Do you currently have any thoughts to hurt or kill yourself? *

Yes

No

Do you currently have any thoughts to hurt or kill others? *

Yes

No

Have you hurt yourself or tried to kill yourself in the past month? *

Yes

No

Have you been admitted to a psychiatric hospital, crisis unit, or psychiatric emergency services in the past month? *

Yes

No

Have you used cocaine, ecstasy, heroin, methamphetamine, non-prescribed pain medication, inhalants, in the past month? *

Yes

No

Are there any disability, worker's compensation, or legal issues related to treatment? *

Yes

No

Do you have Medicare? *

Yes

No

Do you have Medicaid? *

Yes

No

Primary Reason For Visit *

ADHD
Anxiety
Depression
Eating Disorder
OCD
Psych Evaluation
Other
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How did you hear about us? *

Doctor Referral
Therapist Referral
Church
Employer
Family
Friend
Google Search
Insurance Directory
Social Media
Other
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Referral Name

Preferred Method of Communication *

Text
Call
Email
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How will you be paying for your visits? *

Self-pay
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First Name *

Last Name *

Mobile Phone *

Email *

Date of Birth *

Sex Assigned At Birth *

Male

Female

Street Address *

City *

State *

ZIP code *

Upload a photo of the front of your Driver’s License or other Government ID

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I consent to receive non-marketing text messages from Horizon Psychiatry about my appointment reminders and support requests. Message & data rates may apply.

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This application for an appointment will not establish a provider/patient relationship.

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Text or Call: (407) 347-4000

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Address:
1711 Amazing Way #211
Ocoee, FL 34761

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