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Tranquility Behavioral Health Patient Portal
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2024 TREATMENT AND CONSENT FORMS
2024 NEW PT Patient Questionnaires
Appointment Cancellation Request
KWHHWC General Consent
MEDICAL RECORDS/PAPERWORK REQUEST
MEDICATION REFILL REQUEST
NURSE MESSAGE FORM
TBHC NEW PATIENT REQUEST
WAITLIST/ REQUEST FOR SOONER APPOINTMENT
TBHC NEW PATIENT REQUEST
Tranquility BHC NEW PATIENT REQUEST
First & Last Name
D.O.B
*
Phone Number
*
Email
*
PROVIDER Requested
*
-- Please Select --
Dr. Henrietta Evans DNP, APRN, PMHNP-BC,GNP-BC
Dr. DoNesha Tinsley-Obaseki DNP APRN, PMHNP-BC
Please let us know which provider you would like to see. Thank you!
Type of Service Requested
*
Medication Management
TMS Therapy
Psychotherapy
TOVA/ADHD Testing
Autism Testing
Other
Please let us know what type of service you are requesting. Thank you!
Insurance Provider
*
If you do not have insurance please input "no insurance" in the text box.
How did you hear about us?
*
DATE OF REQUEST
*
* Required field
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