Request a New Patient Appointment Tell us a little about yourself and what you’re looking for. We’re here to help. Step 1 of 3 33% HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouI am requesting this appointment for: Myself My child Someone else Please explain:Patient's First Name(Required) First Patient’s Insurance:(Required) BCBS Sanford Health Plan ND Medicaid BCBS Medicaid Expansion Medicare (only accepted for testing appointments) A Medicare Advantage plan Other I don’t have insurance but would like to hear about self-pay options. I’m interested in:(Required) Individual therapy Group therapy Couples therapy Psychiatric medication Psychological testing I’m not totally sure but would like to discuss options. (Check all that apply) Contact PersonShould we contact you or someone else (e.g., a parent or caregiver)?(Required) Me Someone else Contact Person’s First name(Required) First Contact Person’s Phone Number(Required)Contact Person’s Email Address(Required) Email Address Confirm Email Address Thank you for completing this form.The next step is for our scheduling team to review your request and to contact you for additional information, including choosing an appointment date. We aim to respond to all inquiries within one business day.Let’s try to avoid a game of phone tag: When is the best time to reach you?When can we call you?(Required) This Week Next Week What day of the week is best for you?(Required) Monday Tuesday Wednesday Thursday Best Time to Call You(Required)Select A Time9am-10am10am-11am11am-12pm12pm-1pm1pm-2pm2pm-3pm3pm-4pm
