First Step Toward Better Days Ahead - Emerald Therapy Center

Existing Clients* This field is required.If you've met with someone at Emerald within the last 6 months, please call 270.534.5128 to schedule an appointment.

I understand

Name* This field is required.

First Name

Last Name

Birth Date* This field is required.

Gender* This field is required.

Guardian's Name(if applicable)

First Name

Last Name

Phone Number* This field is required.We will contact you to set up your first appointment. In the future we will send you appointment reminders via text.

Area Code

Phone Number

Please Confirm Your Phone Number* This field is required.

Area Code

Phone Number

Email* This field is required.

example@example.com

Address* This field is required.Please use the address listed on the insurance card (if applicable)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Social Security NumberThis is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client or if you prefer to give this to us over the phone when we reach out to schedule your first appointment.

Our Promise: Mental Health Services Cannot Wait.* This field is required.One of our representatives will reach out within 24 business hours to schedule an initial appointment. If unsuccessful, please call 270.534.5128 option #2.

I understand

What can we help you with?* This field is required.

Anxiety

ADHD

Depression

Grief

Couples Counseling

Addiction Treatment

Anger Management

Parenting Classes

MRT- Re-entry

Gender Issues

Eating Disorders

Faith-Based Counseling

Autism Spectrum Disorder

Behavioral Issues

Other

Insurance Carrier:
Policy Holder's Name:   First Name     Last Name
Policy Number:
Group Number:
Group Name:
SSN:    000-00-000

Insurance CardPlease upload a copy of your insurance card front and back (if applicable).

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

First Step Toward Better Days Ahead - Emerald Therapy Center