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CONTACT INFO
CAREERS
Tell us a little about yourself.
This should take less than 2 minutes.
Step
1
of
9
11%
What state are you in currently?
(Required)
FL
Other
We apologize, but we currently only see patients that are in FL.
Are you over 10 years old? (We apologize, we are currently only seeing clients over 18 years of age)
(Required)
Yes
No
We apologize we are currently only seeing patients that are 10 years or older.
Please enter your date of birth.
(Required)
What services are you interested in?
(Required)
Therapy or Counseling
Medication Management
Both
I don't know/Not sure
Other
Do you have thoughts of harming yourself?
(Required)
Yes
No
We care about you. Please call 988 immediately if you have thoughts of suicide or harming yourself.
How did you hear about us?
(Required)
Patients First website
Referral from a Patients First clinic
In-clinic signage/brochure
Email from Patients First
Referral from another healthcare provider
Word of mouth
Magazine Advertisement
Yelp
NextDoor.com
Other website/directory (Psychology Today, etc.)
Other
Past Medical History
Are you currently taking any medication? If so, please provide a list of current medications.
(Required)
Any major surgeries/hospitalizations?
(Required)
Any allergies?
(Required)
Any past counseling history or mental health diagnoses? If so what diagnoses and when?
(Required)
Any psychiatric hospitalizations? If so, when and where?
(Required)
Insurance
Do you plan to use insurance?
(Required)
Yes
No
No worries. We have affordable self pay rates:
Initial Evaluation: $150
25-minute Therapy Session: $90
40-minute Therapy Session: $125
60-minute Therapy Session: $150
Medication Management Consultation: $99
Do have Aetna, Ambetter, BCBS, Cigna Behavioral Health, Humana, Multiplan/ PHCS, United Healthcare/Optum, Medicare, Medicare Advantage, or Tricare?
(Required)
Yes
No
You my want to check with your insurance company, but they are most likely out of network with us. We do have affordable self-pay rates:
Initial Evaluation: $150
25-minute Therapy Session: $90
40-minute Therapy Session: $125
60-minute Therapy Session: $150
Medication Management Consultation: $99
Your insurance is in network.
Please note:
If you have Aetna- Aetna Better Health, Aetna Wellstar, Aetna Community Plan (different from Community Network), they are not in network.
Before scheduling a session, please check with your insurance company to confirm your specific coverage. Co-pays, deductibles, and co-insurance may apply, depending on your specific plan. Note that if your plan includes an annual deductible that has not yet been met, you may be responsible for the full contracted amount. Please see https://www.peachtreemed.com/therapy/ to understand what these costs might be.
Current Symptoms
Check any that apply (1 of 3)
Depressed mood
Feel worthless
Decreased energy
Irritable mood
Mood swings
Socially withdrawn
Increased crying
Self-harm/Injury
Suicidal thoughts
Suicide attempt
Memory problem
Temper outbursts
Insomnia
Low self-esteem
Easily startled
Easily fatigued
Oversleeping
Binge eating
Stealing
Substance use/abuse
Alcohol use/abuse
Trauma
Current Symptoms
Check any that apply (2 of 3)
Obsessive thoughts
Compulsive behavior
Nightmares
Anxiety/Worry
Intense fear
Short attention span
Hyperactivity
Impulsiveness
Daydreaming
Indecisiveness
Perfectionist
Change of appetite
Poor concentration
Easily distracted
Avoids crowds
Muscle tension
Panic attacks
Easily confused
Makes self vomit
Fire setting
Avoids conflict
Exposed to life threatening event
Current Symptoms
Check any that apply (3 of 3)
Hears voices
Sees things that are not there
Racing thoughts
Increased energy
Sexual problems
Stomach aches
Headaches
Rapid heart beat
Reckless of self-abusive behavior
Conflicts with others
Aggressive behavior
Less interested in fun activities
More talkative
Believe that others are plotting against you
Constantly on watch for danger
Feels like things are not real
Fear gaining weight
Gambling problem
Hair pulling
Enjoy being the center of attention
Other
What are the biggest challenges you are facing today, and how can we help?
(Required)
Personal History
What is your relationship status?
(Required)
Single
Married
In a relationship
Recent Breakup
Widowed
Divorced
Separated
Prefer not to answer
Other
Do you have children?
(Required)
What is your highest level of education?
(Required)
No High School
High School/ GED
Bachelors
Masters
Other
Are you employed or unemployed? If employed, what is your current occupation?
(Required)
Family History
What is your Father's first name?
(Required)
What is your Father's age?
(Required)
Please describe your Father's Medical history?
(Required)
Please describe your relationship with your Father.
(Required)
What is your Mother's first name?
(Required)
What is your Mother's age?
(Required)
Please describe your Mother's Medical history?
(Required)
Please describe your relationship with your Mother.
(Required)
Please list any siblings (first name only), their ages, and your relationship.
(Required)
Thank you for telling us more about yourself.
Please click the button below to set up a time to speak with us.