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 Colorado, Tennessee, and Texas. Teen IOP is only offered in Highlands Ranch, CO and Alamo Heights, TX.

Please note: Psychoeducational testing is currently only available in Colorado, Mesa, Nashville, and San Antonio. Locations in Austin coming soon.

Email*

Phone Number*

What type of insurance do you have?*

Zip Code*

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?*

Are you an Active-Duty Service Member?*

Patient Date of Birth*

Date

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.

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