Request an Appointment

Please complete this brief form. A member of our team will contact you regarding services and appointment availability. Fields marked with an asterisk (*) are required.

This form is not for emergencies. If you are experiencing a medical or psychiatric emergency, call 911, call or text 988, or go to the nearest emergency department.

Contact Information

How should we reach you?

Full Name *

Date of Birth *

Callback Number *

Email Address *

Preferred Method of Contact *

Telephone callText messageEmail

May we leave a voicemail identifying Teleemon Behavioral Health & Wellness, PLLC? *

YesNo

Services Requested

What type of service are you seeking? Select all that apply. *

Initial psychiatric evaluationMedication managementTherapyADHD evaluation or treatmentAnxiety or depression treatmentOther

Please briefly describe how we may help you (optional)

Please do not include highly sensitive medical information, detailed symptoms, Social Security numbers, or financial information in this form.

Insurance Information

Help us understand how you plan to cover care.

Insurance Company *

Are you the primary policyholder? *

YesNo

Would you like information about private-pay services if your insurance is not accepted?

YesNo

Appointment Preferences

Tell us what works best for your schedule and location.

Preferred appointment days or times (optional)

State where you will be physically located during the appointment *

Consent

Please review and confirm both statements. *

I understand that submitting this form does not establish a provider-patient relationship or guarantee an appointment. I authorize Teleemon Behavioral Health & Wellness, PLLC to contact me using the information provided. Standard telephone, text-message, or email risks and charges may apply.I confirm that the information provided is accurate and that I am not using this form for an urgent or emergency situation.

Required fields are marked with *

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