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New Patient Appointment Request
Welcome to Olive Branch Behavioral Health Counseling Please complete the form below to request your first appointment. Our staff will review your information, verify your insurance if applicable, and contact you to schedule your appointment. Submitting this form is a request only and does not guarantee an appointment.
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone
*
Date of Birth
*
Appointment Preference
*
In Person
Telehealth
Either
Best Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Best Time Available
Morning
Afternoon
Insurance Information
Please provide your insurance information so we can verify your benefits before your appointment. Completing this section may help speed up the scheduling process.
Preferred Therapist
No Preference
Tripp Hall
Melady Harris
Trevor Rogers
Jarred Coffman
Angie Phillips
If you do not have a preference, please select “No Preference.” We will match you with the first available therapist who best fits your needs.
Reason for Visit
*
Please briefly describe what brings you to counseling or any concerns you would like us to know before your first appointment.
Upload Insurance Card
*
Drag & Drop Files,
Choose Files to Upload
You can upload up to 2 files.
Please upload clear photos or scans of the front and back of your insurance card.
Upload Photo ID
Drag & Drop Files,
Choose Files to Upload
You can upload up to 2 files.
Please upload a valid government-issued photo ID (driver’s license, state ID, passport, or military ID).
Consent & Acknowledgement
*
I understand this is a request for an appointment and does not guarantee an appointment. I authorize Olive Branch Behavioral Health Counseling to contact me regarding scheduling. I certify that the information I have provided is accurate to the best of my knowledge.
Upload Phone Photo
Communication Consent
*
I understand that Olive Branch Behavioral Health Counseling may contact me by phone, voicemail, text message, or email regarding scheduling, appointment reminders, and insurance verification.
Request Appoinmet
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