If you are experiencing a medical or psychiatric emergency, please dial 9-1-1 or go to your nearest emergency room.National Suicide Hotline: 1-800-273-8255TN Crisis Hotline: 901- 577-9400 Interested in Becoming a New Patient? Complete the form below to request a new patient appointment. Please note: Request does not guarantee approval as some clients will not qualify for services or will require a higher level of care. Please Read This Carefully: I understand that I must attend the first appointment in-person. * Yes, I will attend in-person I understand that I am required to keep a credit or debit card on file in order to schedule or receive services. * This applies to Medicare / Medicaid also. Unfortunately, you will not be scheduled without a form of payment on-file. Yes, I know I must keep a credit or debit card on file. I understand that I am required to pay my co-payment at the time of scheduling and that my co-payment is nonrefundable if I do not attend my appointment. * Yes, I will pay my copay / coinsurance fee within 48 hours or my appointment will be cancelled. I understand that I must complete my medical history forms and consent for treatment within 48 of receiving the link or my appointment will be cancelled. * Yes, I will complete my New Patient forms ASAP so that my appointment will not be cancelled. I understand that any appointment requests made after 4pm on Thursday will be processed the following Monday, when the office reopens. The clinic is closed on Fridays. * Yes, I understand the office is closed on Fridays. I understand that DPS does not provide FMLA or Disability services for patients who have been with the practice for less than 12 months. * I agree that I am NOT seeking disability or legal services. I understand that my appointment is NOT confirmed until it has been approved by DPS staff AND I have paid my copay. * Yes, I understand my appointment is PENDING and not confirmed. (REQUIRED) You MUST enter your primary insurance information during scheduling. Because benefits cannot be verified without this information, appointment requests missing insurance information will be denied.
