HELP STARTS HERE

When you’re ready, we’d love to talk with you.

1909 Mallory Lane, Suite 200, Franklin, TN 37067

CALL 615-771-1100

New Patient Request Form

Name

Date of Birth

Email Address

Phone

Address

Insurance Carrier

Primary Insurance ID #

Primary Insurance Group #

Would you like to schedule an appointment with a Psychiatric Medical Provider? Would you like to schedule an appointment with a Psychiatric Medical Provider? Yes No

Would you like to schedule an appointment with a Therapist? Would you like to schedule an appointment with a Therapist? Yes No

Would you like to schedule an appointment for any of the following: Would you like to schedule an appointment for any of the following: TMS Spravato Addiction / Medication-assisted Treatment None of these

Please give us a brief reason for scheduling an appointment

7 + 9 =

WE TAKE MOST MAJOR INSURANCE

*We do not take Tenncare or Medicaid.

For your convenience, we accept all major credit cards as well as cash.

Cool Springs Psychiatric

WE'D LOVE TO TALK WITH YOU

When you're ready to reach out, contact us at 615-771-1100 today. For your convenience you may also complete a new patient request form.

NEW PATIENT REQUEST FORM