Schedule First Evaluation for Psychiatry/Medication

If you are currently receiving therapy, case management, or psychosocial rehabilitation services from Chrysalis Health, then please complete this form and click on “Submit.”

If you are not currently receiving services with Chrysalis Health, and this is the first time, please call (888) 587-0335 to register and schedule an appointment.

Client’s First Name:

Client’s Last Name:

Client’s Date of Birth:

Home address and zip code:

Parent/Guardian full name (if client is 17 y/o or less):

Contact Phone number:

Email address:

Pharmacy Name:

Pharmacy Phone number:

Reason for appointment:

Insurance Name:

Member ID Number:

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