Appointment Request Form
Instructions: Please fill out form completely and email/fax to the requested office and we will contact you to schedule the appointment.
Patient Information
Name: DOB: Sex: Male Female
Address:
Parent Name:
Phone Number: Cell/Home Email:
How did you hear about us: Physician: ____________ Family Friend Internet/Google Other: ______________
Has the patient been professionally diagnosed with any of the following? None ADHD Anxiety Depression
Autism/Asperger’s Learning Disability/Developmental Delay Mood Disorders Bipolar Schizophrenia
Psychosis Suicidal Alcohol/Drug Dependency Other: _____________________________________
List any medications taken for conditions listed above:
__________________________________________________________________________________________________
Insurance Information
Insurance Name: Phone Number:
Policy/Member Number: Group Number:
Policy Holder: DOB:
Appointment Request
Morning Afternoon Specific Dates Requested (if any):
Charlotte Office - Fax: (980) 636-6518 Greensboro Office - Fax: (336) 398-5665
Charlotte Physician Preference: Dr. R. Derek Brugman Dr. Perry Roy
Greensboro Physician Preference: Dr. Amy Stevenson Dr. Emily Thompson
Notes/Special Instructions or Questions
Appointment Details
*For Office Use Only*
Completed By: Scheduled with:
Appointment Date: Appointment Time:
City/State:
Zip Code:
