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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.

OPP Source

1. Will you need any language interpretation services? *

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

6. Have you been diagnosed with or have concerns about dementia? *

Yes

No

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

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

First Name *

Last Name *

Mobile Phone *

Email *

Date of Birth *

Street Address *

City *

State *

ZIP code *

How will you be paying for your visits? *

Self-pay (credit/debit card)
Insurance
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Primary Insurance

Aetna
Beacon
Blue Cross / Blue Shield
Cigna
Commercial
Compsych
Elevance Health
Government Other
Humana
Medicaid
Medicare
Supplemental
Tricare
United Healthcare
Other
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Name of Other Insurance

Primary Insurance ID

Do you have a Secondary Insurance?

Yes

No

Secondary Insurance

Secondary Insurance ID

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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

Fax: (407) 690-7001

Address:
1711 Amazing Way #211
Ocoee, FL 34761

Office Hours:
Mon - Fri: 9am to 6pm

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