Treatment Resistant Appointment Request
* Please be aware we do not bill insurance for these services
First Name
*
Age
*
Cell Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Email
example@example.com
Have You Been Seen at NBM Before?
*
Yes
No
Would Like To Request A Specific Provider?
*
Yes
No
Which office would you like to be seen?
*
Marietta
Alpharetta
Either
Referred from:
Psychatlanta.com
Insurance
Friend
Physician
Therapist
Internet
Family Member
Other
Current Diagnosis:
Depression
Anxiety
Bipolar Disorder
Attention Deficit
Eating Disorder
Substance Abuse
Thought Disorders
Personality Disorder
Other
Past Mental Health Hospitalization?
Yes
No
Current Mental Health Medication List
Interested in Participating in a Clinical Research Trial Program?
Yes
No
Maybe
Legal Issues Or Applying For Disability?
Yes
No
Any Other Information That May Be Helpful
Best Times to Contact You
Morning
Midday
Late Afternoon
Available for Last Minute Cancellation?
Yes
No
Submit
Should be Empty: