Request An Appointment

Two Options To Make Getting Started Easy!

Call us at (606) 594-7479 or click the button below to signup online.

You can complete the online form below to request an appointment.

New Hope APPT Request

Full Name:

Date of birth:

Social Security Number:

Address:

Home Phone:

Cell Phone:

Emergency contact name:

Emergency contact phone number:

List legal guardian’s first and last name if client is under 18:

What is the custodial status if client is under 18:

Marital status of potential client:

What are your living arrangements?

Method of payment:

Do you have medicare?

Please select your insurance provider from the list below:

Primary subscriber on insurance plan:

Do you prefer the soonest possible appointment?

Primary subscriber’s date of birth:

How critical do you feel your current mental health situation is?

Insurance policy number:

Insurance company’s phone number. (May be on back of card).

Do you (or your child) currently receive mental health, substance use treatment, or case management from another agency?

If yes, please list the agency:

Are you currently being medicated for a mental health condition?

If yes, list medications and doses:

Checkboxes

Why are you seeking these services?

Have you ever been hospitalized for any of the above conditions?

Do you or your child use any illegal or controlled substances of abuse?

If yes, please the substances, frequency of use, method of use, and length of time used.

If you are human, leave this field blank.