First Visit Request - Mood Treatment Center

STEP 1: First Visit Request

Thank you for completing this - the more information we have, the faster we can get you scheduled.

Date

Demographics

Patient's Name*

Name you'd like to be called

If DIFFERENT from first name

First Last

Date of Birth*

Age*

Gender*

Other Gender*

Tell us more about your gender identity

Gender listed with your insurance*

Parent/Guardian 1

First Last

Parent/Guardian 2

First Last

Primary Phone*

My primary phone is:*

Secondary Phone

Email*

This will allow you to schedule appointments on our patient portal.

Have you been seen in our office in the past?*

Yes
No

Mood News

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Yes
No

I'd like you to contact me about my first visit by

Check as many as you like!

Phone
Email
Text

Please send appointment reminders to my:

If using text/phone, make sure that phone is listed as Primary below

Text (cell)
Phone (voicemail)
Email
I don't want reminders

How were referred here?

Patient's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Address

Enter a billing address IF DIFFERENT from patient's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment and Insurance

Payment method*

Insurance
Private pay

If you don't see your insurance below, we are probably out-of-network. If that’s the case, select Private Pay above. We can still submit bills for out-of-network benefits, but you would need to pay the full rate at the time of service.

Insurance Name*

Check the front & back of your card to identify your MENTAL HEALTH benefits.

Mental health benefits can be tricky to navigate, but we'll do some of that for you. All we need is the front and back of your insurance card. Most clients take a digital photo and upload it below. If that doesn't work, you can email the front and back ([email protected]), fax (336-201-0538), or mail (MTC New Patients / 713 Marshall St SW, Winston-Salem, NC 27101), or text it (336-722-7266).

Insurance Card (front)*

Insurance Card (back)*

Marital Status

Single
Married
Divorced
Widow

Primary Insured's Name

(if not yourself)

First Last

Primary Insured's Gender*

Primary Insured's Date of Birth*

Treatment Preferences

Which office(s) work best for you?*

Boone (379 New Market Blvd)
Clemmons (2235-A Lewisville-Clemmons Rd)
Greensboro (1901 Adams Farm Pkway)
Winston-Salem at Country Club & Jonestown Rds (104 Cambridge Plaza Dr)
Winston-Salem near WFU (1615 Polo Rd)
Winston-Salem near Downtown & Old Salem (713 SW Marshall St)

Do you need to use telemedicine during the coronavirus pandemic?

Yes
No

Do you need to be seen urgently (in next 2 business days)?

Yes
No

Call or text us (336) 722-7266 as soon as you've finished this form. We can usually get you in within 2 business days.

Best days & times for appointments?

Treatment you are seeking*

All our therapists work with anxiety, depression, bipolar, and relationships. A few have additional training in specialized areas so let us know if you are looking for that...

Specialized areas for therapy...

I prefer to see a therapist who is a...

Man
Woman
Doesn't matter

Below are group therapies we offer throughout the year. We'll let you know when a group with your interests opens up.

Group therapies

Many of our groups are available through teletherapy during the viral pandemic

Anything else you'd like us to know?

We can notify you if sooner appointments become open

Please email me about sooner openings
No thanks

Deposit

We require a $20 deposit to reserve first appointments*

I'd like to make the deposit now
I'd like to make the deposit later

Your deposit secures your appointment and goes toward the first visit. It is refundable if you cancel within 48 hours of your visit.

Billing Name

First Last

If DIFFERENT from patient name

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If DIFFERENT from patient address

Appointment Deposit

Price: $20.00

Total

$0.00

Credit Card

Card Details

Cardholder Name

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