NCHH Online Registration Form

Patient's Email *
example@example.com
DateTime
Patient's Full Name *

First Name Last Name
Patient's Preferred Name *
Patient's Address *

Street Address

Street Address Line 2

City State

Zip Code
Patient's Date of Birth (we see ages 14 and up only) *

Month Day Year
Can we use the patient email to communicate with you, the patient (including email reminders)? *

YES NO
Patient or Parent/Guardian's Mobile Number *

Area Code Phone Number
Can we use your Mobile Number to communicate with you (including text reminders and text communication)? *

YES NO
The Custodial Parent or Legal Guardian should REVIEW AND SIGN this Consent to Treat Minor IF Patient is under 18 years of age or has a legal guardian.

If the patient is under the age of eighteen or unable to consent to treatment, a legal custodian of the Patient will be required to authorize and consent for the initial evaluation and on-going treatment on behalf of the Patient.

I voluntarily consent that my child, or ward, will participate in a mental health evaluation (e.g. psychological or psychiatric) and/or treatment by staff from the Nashville Center for Hope & Healing. The evaluation and treatment will be made by a licensed mental health clinician (a psychotherapist, psychologist, psychiatric nurse practitioner, psychiatrist, or licensed therapist). I understand that following the evaluation and/or treatment, complete and accurate information may be provided concerning each of the following areas:

1. The benefits of the proposed treatment
2. Alternative treatment modes and services
3. The manner in which treatment will be administered
4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
5. Probable consequences of not receiving treatment
6. Expectations regarding the length and frequency of treatment

It may be beneficial to my child, or ward, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s, or ward’s, daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. As a parent or guardian of the patient seeking evaluation and treatment, I may have useful information for the professionals doing the evaluation and ongoing treatment, because of this fact, please disclose all information which can be helpful to the treatment team at any point in the care process. Information can be given verbally, or in written communication.

Treatment will hopefully give benefits, which may include improved cognitive or academic performance, emotional and physical health status, quality of life, and awareness of strengths and limitations.

Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. As the parent or guardian of the patient, I will be responsible for charges. Fees are available to me upon request and may be referenced in the new patient packet.

Information from my child’s, or ward’s, evaluation, and/or treatment is contained in a confidential medical record at the Nashville Center for Hope & Healing, and I consent to its use by staff for the purpose of continuity of my child’s, or ward’s, care. Per Tennessee mental health law, the information provided will be kept confidential with the following exceptions: 1) if my child, or ward, is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise, or 3) if a court order is issued to obtain records.

I have the right to withdraw my consent for evaluation and/or treatment of my child, or my ward at any time by providing a written request to the treating clinician. I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child or my ward. I also attest that I am the legal guardian and have the right to consent for the treatment of this child or ward. I understand that I have the right to ask questions of my child’s, or my ward’s service Clinician about the above information at any time.

Please read the following letter about our clinic and then, begin the application:

Hello and Welcome!

As the medical director of the Nashville Center for Hope & Healing, I want to welcome you and thank you for inquiring about an appointment. Once you submit your application, we will review the application to make sure we can provide the care you are seeking; if we cannot we will refund your deposit and make an appropriate referral.

I am board-certified in psychiatry with the American Board of Psychiatry and Neurology and have trained and seen patients in Nashville and Middle Tennessee since 1992. I have recruited the finest mental health professionals in the area to help you with your needs. In our office, we care for patients from ages 14 & up.

We perform Comprehensive Team Evaluations* and have a reputation for thoroughly evaluating and helping patients get well. The team evaluations include a psychiatric nurse practitioner, a therapist, and a supervising psychiatrist. These evaluations are long and thorough and are more expensive than a typical doctor’s visit. The evaluations generally last 3 to 3.5 hours and are comprehensive and well worth the price. A psychiatrist supervises the comprehensive evaluation and the follow-up care after the initial visit and is consulted by the team as needed in the follow-up. This delegation of service allows you to receive excellent, cost-effective care.

We are a TEAM, and we meet as a team weekly to review cases that we share. Most clinics are just independent clinicians who market the practice together; this is not the case at Nashville Center for Hope & Healing. Further information about our team can be found on our website, www.healnashville.com.

While we offer Comprehensive One-Time Consultations in our clinic for patients and other clinicians in the Middle Tennessee community, we do offer our Comprehensive Team Evaluation at a discount, if you are continuing your care with us following the first visit. Recently, because of the 2020 financial hardships, we started offering Psychiatric Nurse Practitioner-Only evaluations and Therapist-Only. These Psychiatric Nurse Practitioner-Only and Therapist-Only Evaluations are NOT the same as Comprehensive Team Evaluations. There will only be one clinician (a Nurse Practitioner or a Therapist) in the visit.

The Team Evaluation, the Psychiatric Nurse Practitioner evaluation, the therapist evaluation, and all follow-up services are “out-of-network” services in the Nashville Center for Hope & Healing (NCHH), and, as so, patients are asked to pay the full charge of the visit. We are able to file insurance claims for our patients to all commercial insurance companies, but we cannot file with governmental plans such as Medicare, Medicaid, and TennCare as we are not in contract with these entities.

After each encounter, our billing staff can file your claim with your insurance to help you get some reimbursement. Insurance payments typically take a few weeks and will be reimbursed to you directly or if you choose, you can apply any reimbursement as a credit to future visits to our clinic. As all insurance arrangements with patients are unique, insurance reimbursement from your plan is NOT guaranteed. Payment from an insurance company is dependent on the terms of your specific health insurance policy.

In addition to our services, we offer Transcranial Magnetic Stimulation (TMS) and now Esketamine, through an arrangement with the NeuroScience and TMS Centers; we can refer you for a TMS consultation and treatment. Please inquire at the initial appointment scheduling if you are interested in TMS.

We cannot book time for any of the initial evaluations until this application and the deposit payment are complete.  The new appointment deposit is the entire fee of the appointment and covers for the potential of a Missed Appointment or Late Cancellation as our clinicians set aside significant time for each evaluation.

Here are the steps to complete the process:

STEP 1: Complete this private, HIPAA compliant questionnaire Sign all Policies, Select Service(s), & Submit the form with a deposit payment*

STEP 2: Staff will send an email for you to complete your Medical History Questionnaire

STEP 3: Staff will email, or call you with options to schedule your first appointment

* If you are unable to submit the deposit with a credit card payment, print the form, and contact our office manager for an alternative payment form.

We look forward to helping you get a complete comprehensive evaluation, diagnosis, and treatment plan; we believe this is the key to getting well. If you have questions about the process, our clinic, or our team, visit our website www.healnashville.com, or email Whitney Patton, our Front Office Manager, support@healnashville.com.

Sincerely,

Michelle Cochran MD, DFAPA, Director of Nashville Center for Hope & Healing
I have read the letter from the medical director & understand 3-step process to get a new patient appointment. If I need more information I can Email Whitney Patton, support@healnashville.com, OR Call Whitney Patton at 615-379-8600. *

YES NO

Tell us some information about you (the patient)
Why do you want to be a patient in our clinic? What concern has caused you, the patient, to seek help in our clinic? *

0/250
What are your goals and how do you think we can help? *
What do you, the patient, do with most of your days? If you are employed, tell us who employs you. *
Are you (or the patient) taking any medications or other substances for your symptoms? Which ones? (please list all medications, supplements, over the counter or otherwise) - If none, say "NONE" *

0/500
Are you seeing a therapist now? Have you seen a therapist in the past? Have you see a psychiatrist in the past? *

0/500
Have you (or the patient) been hospitalized for symptoms? When and where? *

0/250

STEP 2: Complete the Insurance Section
We are out of network with insurance at NCHH.

If you would like us to submit your claim to insurance when you see other clinicians in the office, we will need information about your policy. If you are privately paying for the appointment (not filing insurance) or using insurance which we are not in-network clinicians, then you do NOT need to fill out this section, and can write NA or NONE in the sections below.

Dr. Cochran does not see in-network patients in this clinic.
What is the Name of the Subscriber (who's name is on the insurance policy, if not the patient)?
Write the word NONE, if you are privately paying for the charges
What is the Date of Birth of the Subscriber?
If we are not filing insurance, write 00/00/0000
Give us the Insurance Subscriber's Address (if the same as the patient's address, just write "same as patient's address above"). If private paying, write "NONE"
The Insured Subscriber's POLICY ID Number?
Write None if private paying
The Insured Subscriber's Group ID Number?
Write None if private paying
What relation is the Subscriber to the patient?
Write-in Myself/ Parent/ Spouse/ Guardian/ or other
Please send a copy of your insurance card (FRONT & BACK) & driver's license with this form if you want us to file for out-of-network benefits

If you lack the technology to do this, please email support@healnashville.com or call 615-379-8600, and we can discuss other ways you could send or drop off your information.
UPLOAD the FRONT of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD the BACK of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD a copy of the patient's or responsible parties drivers license

Browse Files

Cancel of

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Step 1: Complete Questionnaire

Tell us some information about you (the patient)

STEP 2: Complete the Insurance Section

Please send a copy of your insurance card (FRONT & BACK) & driver's license with this form if you want us to file for out-of-network benefits

STEP 3: Review & Agree to Office Policies on our website, www.healnashville.com and complete the Signatures, Service Selection & Submission

Service(s) Selection

If you would like a FREE consultation about TMS or Esketamine, please call 615-348-8200

If you are unable to process a credit card payment above, please print your application and save it as a PDF file and email support@healnashville.com, so staff can process your application another way.