Contact Us - New Patients CRAFT BEHAVIORAL HEALTH

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After you fill out this form, we will contact you. Please note we are not accepting Medicaid Patients. You can also contact us at (904) 379-5928 extension 2. First Appointment Is Always in Clinic. Afterwards Pts Can choose From In Person Or Virtual Appointment. AT THIS TIME WE ARE NOT ACCEPTING ANY MEDICAID PATIENTS

Email *

Phone number *

Location *

JACKSONVILLE. 10175 Fortune Parkway Suite 1106 Jacksonville FL 32256

PALM COAST: 50 Leanni Way UNIT B5, Palm Coast, FL 32137

I am *

Service *

What is your insurance *

First and Last Name *

Date of Birth *

YYYY

Sex *

Female

Male

Height *

Weight in Pounds *

Address including Zip Code *

Preferred Time of Appointment *

Morning

Afternoon

No Preference

How Soon You Need Appointment? *

Within A Week

Within A Month

Mark All That Applies *

I am Employed

I am Disabled

I go to Methadone Clinic

I Use Cane to walk

I use wheel Chair

I use Walker

I use Crutches

I will Bring my Service Dog with me

I will Bring My Emotional Support Animal With Me

I need Bariatric accomodations

Required

Do You Need Any Accommodations *

Please describe Briefly your reason for appointment *

How did you hear about US *

Internet

Friend

PCP

other

Required

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