New Patient Enrollment

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Complete this form to become a new patient. Click "NEXT" at the bottom of each page to advance.

Patient's Full Name *

Patient's Preferred Name

Patient's Date of Birth *

Phone *

Please enter the patient's number or Adult assisting

Email *

Enter any email - except icloud emails

By clicking NEXT below, I agree to receive communications from Synaptic PSYCH via SMS/text message and/or email using the contact information I have provided.

These communications may include appointment reminders, care-related messages, billing notifications, and other practice-related information. Message frequency may vary. Message and data rates may apply.

I understand that I may opt out of SMS at any time by replying STOP and unsubscribe from emails using the link provided in any email. My consent is not a condition of receiving care.

All policies, including privacy policy in patient portal. We do not share patient names, contacts or inquiries.

Patient Preferred Pronoun(s) - Select Any/All That Apply

She/her

He/him

They/Them

Street Address *

City *

State *

Postal Code *

Who is completing this form? *

I am the patient & I am completing this form myself.

I am the legal guardian or parent for the patient who is 18 or older.

I am the parent and/or guardian for a patient under 18.

NONE of the other options above apply and I will stop this process and communicate with the New Patient team,

Thank you for your interest in our offices

Please email - [email protected] or secure text 615-551-5853 before proceeding on behalf of the patient.

Parent/Legal Guardian Name *

What is your relationship to the patient? *

Secondary Parent/Legal Guardian Name

What is their relationship to the patient?

Please upload any divorce/custody, power of attorney, or conservatorship documentation that might be relevant to coordinating patient's care

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

How did you hear of our clinic(s)? *

Please share any details on how you found us:

Were you referred to a specific physician or clinician at Synaptic PSYCH? *

Yes

Clinician Preference (you may pick multiple):

Please note, not all of our clinicians are taking new patients at this time. Thanks for your understanding!

Please provide clear images of both sides of your insurance card for benefit verification: *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Insurance Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Subscriber Information

Name of Subscriber (Policy Holder) *

You can write "me" or the subscriber's name.

Relationship to Patient *

Drop down has options

Date of Birth of Subscriber

Address/City/State/Zip Code of Subscriber *

Write SAME as Patient if applicable.

Have you received treatment in the past at Nashville Center for Hope & Healing, or NeuroScience & TMS Treatment Centers? *

Yes

Family members are generally treated by different clinicians or physicians in order to protect privacy.

Do you have any family members that are current or past patients at Synaptic PSYCH, NeuroScience & TMS Treatment Centers, or Nashville Center for Hope & Healing? *

Yes

What is Your Primary Interest *

TMS - Transcranial Magnetic Stimulation

Esketamine (Spravato) or Ketamine

Prism Self-Neuromodulation Treatment

Telehealth ONLY (Medication Management and/or Therapy) - you must be in Tennessee to receive care.

Evaluation for Diagnosis & Treatment with a Prescriber

Therapy Only (not yet available in our Memphis location)

Therapy & Medication Management

Team Evaluation - Med Mgmt &/or Therapy (not yet available in our Memphis location)

Tell us why you are coming in for an appointment.

EMERGENCY NOTICE: If you are currently in crisis or experiencing a medical emergency, please call 911 or go to the Emergency Room immediately.

What concern has caused you (or the patient) to seek help in our clinic?

How many antidepressant medications have you tried for your symptoms?

none

1 - 2

3 - 4

Over 4

Has your prescribing clinician ever used "augmenter" medications or just antidepressants?

Yes, I have tried Augmentors: Abilify, Seroquel, Adderall, Ritalin, Buspar, Lamictal, or other medications

No, I have only tried antidepressants

Not tried either

Have you ever had any psychiatric hospitalizations? Other medical hospitalizations? *

Yes

If YES, please share any details: When? Where? Why?

New Patient Office Policies

The full office policies are available in the patient portal and are updated periodically. At your first appointment you will be expected to sign the patient policies in order to be a patient in our offices.

This document includes policies that are relevant to the initial scheduling of a new patient appointment in our offices.

Please review and sign the next four policies.

Self-Pay & Insurance Rate Policy

We offer various appointment types with specific private-pay rates for patients without insurance. In some cases, self-pay rates may be more cost-effective than insurance-contracted rates.

New Patient w/ Physician / Psychiatrist = $495
New Patient Interventional Consultation w/Psychiatrist =$495
New Patient w/ Advance Practice Registered Nurse (Nurse Practitioner w/Mental Health Training) =$395
New Patient with Therapist = $250
Team Evaluation (Physician & Therapist)= $745
Team Evaluation (Nurse Practitioner & Therapist) = $645

I have read and agree to the self-pay charges policy. *

Clear

Appointment & Cancellation Policy
To ensure high-quality, evidence-based care, initial appointments are scheduled for 90+ minutes. By signing, you agree to the following terms:
Arrival & Attendance

Early Arrival: Please arrive 30 minutes early to complete required paperwork.
Late Arrivals: If you arrive after half your scheduled time has passed, the appointment is considered missed. If you arrive sooner, you may be seen for the remaining duration.
Telehealth Option: If you cannot attend in person, virtual visits may be available.
Patients must be physically located in Tennessee during the visit.
Medicare Patients: Per federal law, you must be seen in person for your initial visit and at least once annually thereafter.

Cancellations & Missed Appointments

Notice Required: Cancellations must be made at least
three (3) business days in advance by 4:00 PM.
Late Fees: If you miss your appointment or fail to provide the required notice (including for illness, transit, or weather), you will be charged the full Self-Pay Rate.
Insurance: These fees cannot be billed to insurance and will be charged to the credit card on file.

I agree to the Appointment and Cancellation Policy and authorize the use of my credit card for associated charges. *

Clear

Credit Card & Payment Authorization Policy
We require a valid credit card on file via our patient portal. By signing, you agree to the following financial terms:

Payment Terms

Automatic Charges: Your card will be charged for all balances determined by your clinician or insurance, including copays, coinsurance, deductibles, non-covered services, and missed/late cancellation fees.
Timing: While cards are validated in advance, charges are processed on the day of your appointment or once insurance responsibility is determined.
Payment Maintenance: If your card expires or is declined, you must provide a new form of payment immediately. Failure to maintain a valid payment method is grounds for termination of care and appointment cancellation.

Insurance & Authorization

Coordination: We collect patient-responsibility amounts (copay/deductible) at the time of service and bill in-network insurance for the remainder.
Information Release: You authorize Synaptic PSYCH to release any information required to process insurance claims and secure benefits.

I have read, understood, and agree to this policy. I authorize Synaptic PSYCH to charge my credit card for clinical appointments and associated fees. *

Clear

Insurance Policy and In-Network Coverage

Most of our clinicians are in-network with Cigna, Aetna (including Meritain), United Healthcare, Optum, OSCAR, BCBS, Anthem, and Medicare. Note that only specific therapists are in-network; please verify your provider’s status with us.

If we are in-network with an insurance provider, we will file electronic claims on your behalf, provided you have supplied accurate insurance info and relevant medical history (diagnosis, past treatment, and records). Patients are responsible for copays, coinsurance, and deductibles as defined by policies.

Verification: While we attempt to verify benefits beforehand, coverage is not guaranteed. Claims may process as out-of-network due to plan exclusions, HMO restrictions, or third-party administrators.
Patient Responsibility: We strongly recommend confirming your behavioral health benefits with your insurer prior to your visit. If insurance denies a claim, you agree to pay our Self-Pay Rates.

Excluded Plans

Medicare Advantage & Managed Care: We are not contracted with Medicare Advantage, "carve-out" plans, or Ambetter.
TennCare & Medicaid: We do not accept these plans as primary insurance. We can only see patients with TennCare/Medicaid if it is secondary to a contracted primary plan. Otherwise, we recommend local community mental health centers for these services.

By signing, as the adult patient or legal guardian/parent of the patient, that I agree to this insurance policy and accept financial responsibility for services not covered by my insurance. *

Clear

If you are ready to schedule a call with our New Patient Intake or Interventional Team, CLICK SUBMIT below, and check your text or email for the link to schedule the appointment.

Thank you for your interest in our offices

Subscriber Information

Thank you!