*VIRTUAL TELEMEDICINE APPOINTMENTS ONLY
Appointments are on Tue, Wed & Thu
*Monday is an administrative day
CLOSED Fri, Sat & Sun

TFCPC Appointment Request Form

    **This form is not HIPAA-compliant.**
    **Please call our office at 770-376-6726 if you prefer to answer these questions via telephone**  
    However, If you are comfortable with completing and submitting the form below, then please continue.  Every item requires an answer, so please read each question very closely before answering.  Write N/A in the text boxes for items not applicable to you.  Please remember to click the SUBMIT     button when done.  Once we have reviewed your form, we will contact you by telephone to complete the scheduling process.  Afterward, you will receive a confirmation email with required paperwork attached to it.  We must have these completed documents in our possession before you may be seen.   Forms submitted outside business hours will not be reviewed or responded to until the next business day.  We are open Monday through Thursday from 7 AM until 7 PM.  Thank you.
    **For emergencies or safety issues, either call 911 or go to the nearest emergency room.**
    Please note that we do NOT accept insurance or bill insurance companies.
    Please note that we cannot accept patients using Medicare, Tricare, Peachcare, Medicaid
    Please note that some situations are not appropriate for telemedicine.
    Please note that we do not treat substance use disorders.
    Please note that we do not treat Schizophrenia or psychotic disorders.
    Please note that we do not treat ADHD.
    Please note that you must be in the state of GA to receive our services.
    Please visit our FAQ page or our Services page for more information.
    **PLEASE READ: This form is only for people seeking our clinical services (doctor-patient, consultation or 2nd opinion). It is not intended for people seeking forensic psychiatry evaluations.   Instead, please call our office.  Thank you.
    **STOP** If you answered YES to this question please discontinue completing this form.  Instead, please call our office to learn more about our forensic psychiatry services.  This form is only for people seeking clinical services. Thank you.**
    **STOP** If you answered YES to this question please discontinue completing this form.  Instead, please call our office to learn more about our forensic psychiatry services.  This form is only for people seeking clinical services. Thank you.**
    **STOP** If you answered YES to this question, then please discontinue completing this form.  Instead, please contact a mental health provider who specializes in substance abuse/dependence.  We do not offer such services. Thank you.**
    **STOP** If you answered YES to this question and you are still struggling with substance abuse/dependence, then please discontinue completing this form.  Instead, please contact a mental health provider who specializes in substance abuse/dependence.  We do not offer such services.   However, if you are in recovery and substance abuse/dependence is no longer an issue for you, then please continue with completing this form. Thank you.**
    **STOP** If you answered YES to this question and the attempted suicide was recent, then please stop completing this form.  Instead, please either go to your local ER or contact a psychiatric hospital.  We are not an acute care facility.**

Thank you!  May the face of God shine on you and give you everlasting peace!

Redemptive healing for your soul, mind, body & spirit...
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770-376-6726