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 participants meet each Monday through Thursday, three hours daily, for five to six weeks. IOP is only available in Colorado, Tennessee and Texas.

Please note: Psychoeducational Testing is currently only available in Colorado. Locations in Arizona, Tennessee and Texas are 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.

gclid

utm_source

utm_medium

utm_campaign