Jump to Content
Tranquility Behavioral Health Patient Portal
Home
Forms
Available Forms
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
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
