Messaging Form

Name	Date of Birth
E-mail	Phone
Select your preferred provider:	Select your preferred location:

This is my first visit to 1Alliance CPS.

Insurance Provider:

Member ID:

First Appointment Option:	Second Appointment Option:	Third Appointment Option:
Select your appointment date: Select your preferred time slot:	Select your appointment date: Select your preferred time slot:	Select your appointment date: Select your preferred time slot:

Referral (if applicable)

Referring entity (agency, person, etc)

Phone number of referring entity

Reason for referral

Additional Comments

Please note that due to HIPAA, our practice will follow up directly with the person seeking counseling and we are unable to provide clinical information such as appointment attendance without client's consent.

Please, keep in mind that this is not a confidential media. If you need to contact a therapist about a sensitive, non-urgent, matter, consider using our Confidential Message page, or calling us directly at (678)310-6631.