Self Referral Request (Launched 4.24.2025)

Are you a new or existing patient?
Patient Name

Patient First NamePatient Last Name
What type of appointment are you seeking?
Please note: IOP groups meet for 5-6 weeks. Adult IOP is available in Arizona, Colorado, Tennessee, and Texas.
Please note: Educational Assessments are not currently available in Florida.
Email
Phone Number
Format: (000) 000-0000.
What state will care take place in?
Please note, Family Care Center only serves patients in Arizona, Colorado, Florida, Tennessee and Texas at this time.
What is your preferred Colorado clinic?
What is your preferred Arizona clinic?
What is your preferred Tennessee clinic?
What is your preferred Texas clinic?
What type of insurance do you have?
Photo of Front of Insurance Card

Cancelof
Photo of Back of Insurance Card

Cancelof
Zip Code
Why are you seeking psychoeducational testing?
Please explain why you are seeking psychoeducational testing (other):
Are you an Active-Duty Service Member?
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For what condition are you seeking TMS services? (i.e. depression, anxiety, OCD, etc.)
Has the patient trialed at least 2 anti-depressant medications?
Message
By providing a telephone number and submitting this form you are consenting to be contacted by phone and SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
gclid
utm_source
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utm_campaign
GA Client ID
GA Session ID
Ad Click ID
Page URL
Should be Empty: