Request an Appointment – Bien Mind Psychiatry

Welcome to Bien Mind Psychiatry!

We are excited to support you on your journey to mental wellness. This form allows you to schedule a 60-minute initial psychiatric evaluation.

Name

Date of birth

Phone Number

Which state/city are you located in

Reason for visit?

Insurance Name

Member ID

Group Number

Address associated with your insurance

If you are not the primary insurance card holder, please enter their full name, DOB, and address. (type N/A if not applicable)