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    • STEP 2: New client form
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(336) 722-7266
frontdesk@moodtreatmentcenter.com
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First Visit Request[email protected]moodtreatmentcenter.com2020-08-27T10:23:56-04:00
  • STEP 1: First Visit Request

    Thank you for completing this - the more information we have, the faster we can get you scheduled.
  • Date Format: MM slash DD slash YYYY
  • Demographics

  • If DIFFERENT from first name
  • Date Format: MM slash DD slash YYYY
  • Tell us more about your gender identity
  • This will allow you to schedule appointments on our patient portal.
  • Get monthly email updates on natural health, therapy programs, and our free audio guides. Unsubscribe anytime.
  • Check as many as you like!
  • If using text/phone, make sure that phone is listed as Primary below
  • Enter a billing address IF DIFFERENT from patient's address
  • Payment and Insurance

  • 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.
  • 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).
  • (if not yourself)
  • Date Format: MM slash DD slash YYYY
  • Treatment Preferences

  • 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.
  • 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...
  • Below are group therapies we offer throughout the year. We'll let you know when a group with your interests opens up.
  • Many of our groups are available through teletherapy during the viral pandemic
  • Deposit

    Your deposit secures your appointment and goes toward the first visit. It is refundable if you cancel within 48 hours of your visit.
  • If DIFFERENT from patient name
  • If DIFFERENT from patient address
  • Price: $20.00
  • $0.00
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