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Initial Appointment Request
Fill out the form below to request your initial appointment at The Well Premier Psychiatric Services.
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* Indicates required question
First and Last Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Phone Number:
*
Your answer
Email Address:
*
Your answer
Reason for Seeking Mental Healthcare:
*
Your answer
Location preference:
*If you are currently being treated with a controlled substance (benzodiazepines,
psychostimulants, etc.), initial appointments should be conducted in the office. Telehealth may
be an option for follow-up appointments.
In-person
Telehealth
Counselor/Therapist Name (if applicable):
Your answer
Healthcare Insurance Company:
*
Your answer
Health Insurance Member ID Number:
*
Your answer
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