New Patient Forms

Start Your Journey To Better Mental Health

To get started on your journey to better mental health, schedule an appointment and complete the forms below.

All fields are required. If the answer is no answer put “NA”.

If you would rather print the forms and fax them to us please download the forms here and fax them to (337) 806-9339 or email them to [email protected]

Step 1 of 10

MM slash DD slash YYYY
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Work Address(Required)


Relation To Subscriber(Required)
Relation To Subscriber(Required)
I understand that all psychiatric evaluations or screenings in preparation for surgery will not be filed with insurance and are subject to private payment by the patient at the time of the evaluation/screening.(Required)

Appointed Pharmacy

Include the amount you are taking at each dose and how often per day you take each medication. I.E. Asprin 1mg twice per day.

Emergency Information

Spouse/Partner Name(Required)
Signature of Patient or Guardian(Required)

Let’s Talk


215 Rue Fontaine
Lafayette, LA 70508

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New Iberia

605 S Lewis St
New Iberia, LA 70560

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Office Hours

Mon – Thurs: (8 am to 4:30 pm)
Fri: (8 am to 12 pm)
Sat – Sun: (Closed)