Online Self-Referral Form | Sherbondy's Psychiatric Solutions

Fill this out on your phone or computer and attach photos of your driver's license and the front and back of your insurance card. We do not accept Medicare. Fields marked * are required.

Step 1 of 5

Patient Information

Please tell us about the person who will be seen.

Full name* Please enter the patient's name.

Sex*

Male Female

Please choose one.

Address* Please enter an address.

City* Required.

State* Required.

Zip* Required.

Cell phone* Please enter a phone number.

Home phoneoptional

Date of birth* Please enter a date of birth.

Age

Social Security #* Please enter all 9 digits.

Emailoptional, so we can confirm receipt

Emergency contact name* Required.

Emergency contact phone* Required.

Step 3 of 5

Insurance

Copy these from the front of your insurance card. We do not accept Medicare.

Insurance company name* Required.

Policy ID #* Required.

Insurance phone #on the back of your card

The patient is the policy holder

Policy holder name* Required.

Relationship to patient* Required.

Policy holder date of birth* Required.

Policy holder SSN* Please enter all 9 digits.

Step 4 of 5

Attach Your Documents

Take a clear photo or choose a file. Photos (JPG, PNG, HEIC) and PDFs work. Make sure all four corners and the text are readable.

Driver's licenseFront of card, or a photo ID

Insurance card: frontTap to take a photo or choose a file

Insurance card: backTap to take a photo or choose a file

Please attach all three documents.

Step 5 of 5

Review & Send

We will be happy to assist you with an appointment once we have received your information.

How did you hear about us?optional

Please tell us more

I confirm the information above is accurate and I authorize Sherbondy's Psychiatric Solutions to use it, including my insurance information, to schedule my care. * Please check the box to continue.

Your information is sent to our office over an encrypted (HTTPS) connection and is used only to schedule your care. If you would rather not use the form, you can download the PDF or call (864) 987-9747.

Received

Thank You

We have received your self-referral. Our team will review it and reach out to schedule your appointment. If you need us sooner, call (864) 987-9747 during office hours.

If you are experiencing a psychiatric emergency, call 911, go to your nearest emergency room, or call or text 988.

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Patient Information

Reason for Referral

Insurance

Attach Your Documents

Review & Send

Thank You