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What state are you in currently?(Required)

Other

We apologize, but we currently only see patients that are in GA.

Is the patient over 10 years old? (We apologize, we are currently only seeing clients over 10 years of age)(Required)

Yes

We apologize we are currently only seeing patients that are 10 years or older.

Please enter your date of birth.(Required)

What services are you interested in?(Required)

Therapy or Counseling

Medication Management

Both

I don’t know/Not sure

Other

Do you have thoughts of harming yourself?(Required)

Yes

We care about you. Please call 988 immediately if you have thoughts of suicide or harming yourself.

How did you hear about us?(Required)

Peachtree Immediate Care website

Referral from a Peachtree Immediate Care clinic

In-clinic signage/brochure

Email from Peachtree Immediate Care

Referral from another healthcare provider

Word of mouth

Magazine Advertisement

Yelp

NextDoor.com

Other website/directory (Psychology Today, etc.)

Other

Past Medical History

Are you currently taking any medication? If so, please provide a list of current medications.(Required)

Any major surgeries/hospitalizations?(Required)

Any allergies?(Required)

Any past counseling history or mental health diagnoses? If so what diagnoses and when?(Required)

Any psychiatric hospitalizations? If so, when and where?(Required)

Insurance

Do you plan to use insurance?(Required)

Yes

No worries. We have affordable self pay rates:

Initial Evaluation: $150
25-minute Therapy Session: $90
40-minute Therapy Session: $125
60-minute Therapy Session: $150

Medication Management Consultation: $99

Do have Aetna, Ambetter, BCBS, Cigna Behavioral Health, Humana, Multiplan/ PHCS, United Healthcare/Optum, Medicare, Medicare Advantage, or Tricare?(Required)

Yes

You my want to check with your insurance company, but they are most likely out of network with us. We do have affordable self-pay rates:

Initial Evaluation: $150
25-minute Therapy Session: $90
40-minute Therapy Session: $125
60-minute Therapy Session: $150

Medication Management Consultation: $99

Your insurance is in network.
Please note:
If you have Aetna- Aetna Better Health, Aetna Wellstar, Aetna Community Plan (different from Community Network), they are not in network.
Before scheduling a session, please check with your insurance company to confirm your specific coverage. Co-pays, deductibles, and co-insurance may apply, depending on your specific plan. Note that if your plan includes an annual deductible that has not yet been met, you may be responsible for the full contracted amount. Please see https://www.peachtreemed.com/therapy/ to understand what these costs might be.

Current Symptoms

Check any that apply (1 of 3)

Depressed mood

Feel worthless

Decreased energy

Irritable mood

Mood swings

Socially withdrawn

Increased crying

Self-harm/Injury

Suicidal thoughts

Suicide attempt

Memory problem

Temper outbursts

Insomnia

Low self-esteem

Easily startled

Easily fatigued

Oversleeping

Binge eating

Stealing

Substance use/abuse

Alcohol use/abuse

Trauma

Current Symptoms

Check any that apply (2 of 3)

Obsessive thoughts

Compulsive behavior

Nightmares

Anxiety/Worry

Intense fear

Short attention span

Hyperactivity

Impulsiveness

Daydreaming

Indecisiveness

Perfectionist

Change of appetite

Poor concentration

Easily distracted

Avoids crowds

Muscle tension

Panic attacks

Easily confused

Makes self vomit

Fire setting

Avoids conflict

Exposed to life threatening event

Current Symptoms

Check any that apply (3 of 3)

Hears voices

Sees things that are not there

Racing thoughts

Increased energy

Sexual problems

Stomach aches

Headaches

Rapid heart beat

Reckless or self-abusive behavior

Conflicts with others

Aggressive behavior

Less interested in fun activities

More talkative

Believe that others are plotting against you

Constantly on watch for danger

Feels like things are not real

Fear gaining weight

Gambling problem

Hair pulling

Enjoy being the center of attention

Other

What are the biggest challenges you are facing today, and how can we help?(Required)

Personal History

What is your relationship status?(Required)

Single

Married

In a relationship

Recent Breakup

Widowed

Divorced

Separated

Prefer not to answer

Other

Do you have children?(Required)

What is your highest level of education?(Required)

No High School

High School/ GED

Bachelors

Masters

Other

Are you employed or unemployed? If employed, what is your current occupation?(Required)

Family History

What is your Father's first name?(Required)

What is your Father's age?(Required)

Please describe your Father's Medical history?(Required)

Please describe your relationship with your Father.(Required)

What is your Mother's first name?(Required)

What is your Mother's age?(Required)

Please describe your Mother's Medical history?(Required)

Please describe your relationship with your Mother.(Required)

Please list any siblings (first name only), their ages, and your relationship.(Required)

Thank you for telling us more about yourself.
Please click the button below to set up a time to speak with us.

Tell us a little about yourself.

Past Medical History

Insurance

Current Symptoms

Current Symptoms

Current Symptoms

Personal History

Family History

Thank you for telling us more about yourself.Please click the button below to set up a time to speak with us.

Thank you for telling us more about yourself.
Please click the button below to set up a time to speak with us.