New Client Appointment - Reliant Family Psychiatry

Welcome to Reliant Family! We are excited to meet you and begin your journey towards better health and wellness.

Important: Reliant Family team will reach you back with an appointment after insurance verification within 24 hours. 

First Name: *
Last Name: *
Date of Birth: *
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Gender: *
Email Address: *
Please provide a valid email. This will be used to send you the appointment confirmation. 
Phone Number: *
Please provide a valid phone number. This will be used to send you the appointment confirmation via SMS. 
Street Address:
City: *
Zip Code: *
Reason of Visit / Your Notes: 
Type of Appointment: *
Available Days/Time: 
Monday
Tuesday
Wednesday
Thursday
Friday
9:00 a.m
10:00 a.m
11:00 a.m
12:00 p.m
1:00 p.m
2:00 p.m
3:00 p.m
4:00 p.m
5:00 p.m
Health Insurance Name/Type:
 *
Member(Policy) Number/ID:
 *
if you have chosen SELF-PAY,  please type Cash.  
Group Number/ID: (Optional)
What is the best way to send the appointment confirmation? 
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How did you hear about us?
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"I confirm that all of the information provided above is correct and belongs to me."

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