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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
MEDICAL RECORDS/PAPERWORK REQUEST
MEDICATION REFILL REQUEST
NEW PATIENT REQUEST
NURSE MESSAGE FORM
WAITLIST/ REQUEST FOR SOONER APPOINTMENT
WAITLIST/ REQUEST FOR SOONER APPOINTMENT
WAITLIST/ REQUEST FOR SOONER APPOINTMENT
Patient First Name
*
Patient Last Name
*
D.O.B.
*
Email Address
*
Phone Number
*
PROVIDER
-- Please Select --
Dr. Henrietta Evans DNP, APRN, PMHNP-BC,GNP-BC
Dr. DoNesha Tinsley-Obaseki DNP, APRN, PMHNP-BC
Please let us know what type of service you are requesting. Thank you!
Type of Appointment Needed
*
-- Please Select --
MED MANAGEMENT
PAPERWORK APPOINTMENT
THERAPY
OTHER
Insert requested Appointment Date
Appointment Date Needed
*
Do you have an upcoming appointment date?
*
YES
NO
If YES, enter your UPCOMING appointment date
Chief Complaint/Comments
DATE OF REQUEST
*
* Required field
Submit Form
