Request an appointment
Welcome to Allied Behavioral Health Solutions
Please complete this form to the best of your ability. If you have any questions or would like to speak with someone about our services, please call our office at (615) 292-3661.

Important: In Tennessee, individuals age 16 and older are considered adults for behavioral healthcare.
If the client is 16 or older and seeking services, they must complete this form themselves.
(This does not apply to referrals submitted by healthcare providers.)

Please note: We are unable to provide immediate or urgent services. If you are experiencing a mental health emergency, thinking about suicide, or are in need of immediate assistance, please go to the nearest emergency room, call 911, or contact the Suicide and Crisis Lifeline by calling 988 or texting 741741.

Before completing the form, please review our FAQ to learn more about what services we offer. 
Sign in to Google to save your progress. Learn more
đźš« Please Do Not Submit Duplicate Requests
If you have already submitted this form, or if you have previously requested services by phone, please do not complete the form again.  Duplicate requests for the same client can slow down the scheduling process for everyone.

If you need to update information or check the status of a referral, please contact our office directly.

Are you requesting an appointment for yourself or someone else?

 *
If you are a DCS or Youth Villages caseworker, please select “My child or a child in my custody.” Please note: If you are a foster parent of a child in the custody of the State, this form must be completed by a legal representative of the State, such as a DCS caseworker.

Client's Full Legal Name

 *
If this is a referral for a child under the age of16, please enter the child's name here.

Client's Preferred Name

(For example, a nickname or name they go by day-to-day)

Client's Date of Birth

 *
If the client is 16 or older, they must complete this form themselves.
MM
/
DD
/
YYYY
Legal Guardian's Full Name
If the client is under 16, please enter the legal guardian’s first and last name.  If the child is in DCS or State custody, enter the name of the child’s current Family Service Worker, not the foster parent.

Client or Legal Guardian's Phone Number

 *
If the client is a child under the age of 16, please enter the legal guardian’s phone number here.

Client or Legal Guardian's Email Address

 *
If the client is under 16, please enter the legal guardian’s email address.

What is the preferred method of contact for the client or legal guardian?

Clear selection

What city does the client live in?

 *
Please note: Allied Behavioral Health Solutions can only provide services to clients located within the state of Tennessee, including for virtual therapy.

Are you open to receiving therapy via secure two-way video (telehealth)?

 *
In some cases, this option may reduce your wait time to be connected with a clinician based on your location.

If you are interested in in-person therapy, which of the following office locations would be most convenient for you?

 *
Availability may vary by office. Your response helps us connect you to services as quickly as possible.
Required

Will you be using health insurance or an Employee Assistance Program (EAP) to assist with the cost of services?

 *

Would you be open to working with a clinical intern?

 *

We offer sessions with clinical interns who are supervised by licensed therapists.
Interns are able to see clients who have TennCare or are not using insurance, often at a reduced rate.

Areas of Concern

 *
Please check any issues or topics you’d like support with. This helps us better understand your needs and match you with the right clinician.
Required

Please share more about the reason you're requesting an appointment or making this referral. *
This helps us understand your needs and match you with the right services. If you have any preferences for the kind of therapist you’d like to see — like someone with a certain background or training — feel free to include that here too.
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Allied Behavioral Health Solutions.

Does this form look suspicious? Report

Google Forms