Your Journey to Wellness Awaits

Patient Name *

First Name

Last Name

Phone *

Phone number where we may contact you if needed

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Patient Age Group *

(Select one)

Child (6-12 y/o)

Teen (13–17 y/o)

Adult (18–64 y/o)

Appointment Type *

Please select your preferred appointment type. Choose only one option.

In-Office Appointment (Normal, IL). 1100 Beech St, Bldg 10, Suite 6, Normal, IL 61761

Telepsychiatry Appointment (via Osmind). Secure virtual appointment using Osmind. You will receive instructions prior to your session.

Services

Which services or approaches are you interested in? (Select all that apply)

Diagnostic Evaluation (Initial Psychiatric Assessment)

ADHD Evaluation

Medication Management

Spravato® (Esketamine) – Coming Soon!

Brief Supportive Therapy / Counseling

Medication + Therapy Combination

Supplements / Integrative Approaches

Pharmacogenetic Testing (gene-based med matching)

Our dog Lady present during follow up appointments

Other

Payment Method *

Please select your payment method for services. Choose only one.

Self-Pay (Private Pay). I understand full payment is required at the time of service.

Commercial Insurance: Blue Cross Blue Shield of Illinois (BCBS IL). I authorize Gravity Psychiatry & Wellness PLLC to bill my insurance and understand that I'm responsible for copayments, deductibles, or services not covered.