Online Referral (For New Clients)

 Our clinics are open and appointments are via video now due to Covid. Please fill the information below and click the submit option at the bottom. If there any issues, please use Laptop or Computer. You also can try to use Google chrome browser on smartphone if needed. Please resubmit the request again if you do not get reply within 24 hours or emails us at info@piedmontbs.com

Checkboxes *

• I agree and understand that making or attending an appointment does not guarantee any specific treatment, medications and outcome

Name *

First

Middle

Last

Gender *MaleFemale

Date of Birth *

Email Address: *

Phone *

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Reasons for Appointment or Referral *

Referent Name (Your Name if No Referral) *

Referent Relationship *MyselfParent or Legal GuardianTherapistTeacherMedical ProviderCourt/LegalHospital/ER/Post DischargeOther not listed above

Current Medications List *

Past Medications List (if applicable) *

Name of Insurance Company (if any) *

Insurance Member ID Number (if any otherwise write N/A) *

Secondary Insurance Name (if any otherwise write N/A) *

Secondary Insurance ID Number (if any otherwise write N/A) *

Urgency of Appointment *

• Urgent-Same Day or Next Available
• Non Urgent- My Preference is below

My 1st Appointment Preference

Date

Time

My 2nd Appointment Preference

Date

Time

My 3rd Appointment Preference

Date

Time

Appointment Type *Cary/Raleigh, NC (in Clinic)Ashburn/Lansdowne, VA (in clinic)Video Appointment (From Home)TMS Spravato/Ketamine

How you heard about Us *Google SearchPsychology Today (Directory)Other online SearchFamily/FriendHospital/ERFacebookMedical Provider or Therapist

Upload Picture of Insurance Card (Front)

Click or drag a file to this area to upload.

Upload Picture of Insurance Card (Back)

Click or drag a file to this area to upload.

Credit/Debit Card or HSA Card Number

Card

Name on Card

Zip code of Credit/Debit Card/HSA Holder

Card Verification Code (3 or 4 digit code)

Credit Card Type

• Visa
• Mastercard
• American Express
• Discover

I have read the policies below (mentioned in the below link). By signing below (electronically), I acknowledge that I understand and accept all the information listed in the polices and I give the consent for treatment. https://drive.google.com/file/d/1yh37B-9olan8s_o8U0qoWxA8f01IdAao/view?usp=sharing *

• I agree & acknowledge

I have read the below form (mentioned in the below link). By signing below (electronically), I allow Piedmont Behavioral Services, PC to release and/ or exchange information (including oral communications) with my previous and future providers for treatment and continuation of care. https://drive.google.com/file/d/1h6dKpt5634icY7sR4X9YKOENk1HkcDcJ/view?usp=sharing *

• I agree & acknowledge

Signature (Please Type Full Name) *

Signature *

Clear Signature

Signature Date *

Name

Submit