Request Appointment

To request an appointment, please complete the client request form below or call us at 888-988-6329.

Anyone seeking Behavioral Health services from our Mental Health Rehabilitation program will need to complete an assessment with Texas Care. Call or complete the form below to get started.

Appointment Questionnaire

Name:

Date of Birth:

Address:

City:

State:

Zip Code:

Phone:

E-mail:

Preferred Method:

Who is Seeking Help:

Primary Insurance:

Primary Insurance Carrier:

Policy Holder Name:

Policy ID Number:

Group Number:

Insurance Contact Number:

Relationship to Policy Holder:

Policy Holder Date of Birth:

Type of Service:

Note: Due to COVID-19, all services are provided via telehealth and video chat.

Type of Treatment:

What else would you like us to know?

Enter the Characters Shown Below

Medicaid - Private Insurance - Self Pay

Houston · Dallas/Fort Worth · El Paso · Beaumont · Tyler · San Antonio

Request Appointment

Appointment Questionnaire

Superior Healthplan

Optum

United Healthcare

Blue Cross Blue Shield of Texas

Cigna

Magellan Health