Become A New Patient

Become A New Patient - Steps

First Name

Last Name

Phone Number

Date of birth

I agree to receive text messages about appointments, reminders, and updates. Message and data rates may apply. I can opt out anytime.

How can we help?

Note: if this is about emotional support animal (ESA) letters, please use this form:
https://toptierpsych.com/esa-letter-request-form/

A few more questions...

Do you plan to use insurance?

Yes

We believe in transparent pricing for self-pay (not using insurance) visits:

Initial visit: $275

Follow-up visits: $125

Would you like to proceed?

Yes

Please upload a picture of the FRONT of your insurance card

File Upload

Choose File

Please upload a picture of the BACK of your insurance card

File Upload

Choose File

Please upload a picture of the FRONT of your government-issued ID (driver's license, passport, state ID, etc)

File Upload

Choose File

Last question - what is your home address?

This helps us find out if we serve your area.

Address

Address Line 1

Address Line 2

City

Zip Code