Tranquility Behavioral Health Patient Portal

First & Last Name

D.O.B *

Phone Number *

Email *

PROVIDER Requested *

Please let us know which provider you would like to see. Thank you!

Type of Service Requested *

Medication Management

Autism Testing

Concussion Testing

ADHD Testing

GeneSight Testing

Nutrigenomics Testing

Neurocognitive Testing

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.

Subscriber ID *

Group Number *

Put N/A if you do not have a group number

How did you hear about us? *

DATE OF REQUEST *

* Required field