Request Appointment

To request an appointment, please complete the client request form below or call us at 888-988-6329

Anyone seeking Behavioral Health services from our Mental Health Rehabilitation program will need to complete an assessment with Texas Care. Call or complete the form below to get started.

Appointment Questionnaire

Name

Date of Birth

Phone

Address

City

State

Zip Code

Preferred Contact Method

Who is Seeking Help?

Primary Insurance:

Primary Insurance Carrier

Policy Holder Name

Policy ID Number

Group Number

Insurance Contact Number

Relationship to Policy Holder

Policy Holder Date of Birth

Type of Service

Type of Treatment

What Else Would You Like to Know?

Enter the Characters Shown Below