Get started in moments. Please note: Blueprint currently provides coverage in Tennessee. Fill out a quick survey, and we’ll try to be in touch within 24 hours. Which provider would you like to schedule an appointment with? * No preference Steven Taylor Berry, PMHNP-BC Bailey Dryden, PMHNP-BC Kylie Link, PMHNP-BC Tiffany Wiseman, PMHNP-BC Choose your health insurance provider (if available). * BlueCross BlueShield Aetna UnitedHealthcare Cigna UMR VA Community Care Network Magellan Tricare Self Pay Name of Patient * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Can we send you text messages at this number? * Yes No Can we leave you voicemails at this number? * Yes No Email * What is the reason for your visit? * Have you been diagnosed with any mental health conditions? * What medications are you currently taking? Please list them, including dosage if known. * Have you taken medication for any mental health conditions in the past? If so, please list the medications and any relevant details. * Are you pregnant or planning to be? * Yes, currently pregnant No, not pregnant and not planning to be No, but planning to be Unsure Not applicable Have you ever been admitted to a mental health hospital for more than 48 hours? * Yes, within the past year Yes, more than a year ago No Prefer not to answer If yes, please list the month and year of each hospitalization. * Please let us know how you discovered Blueprint Telehealth (e.g., friend, social media, online search, etc.). * We provide psychiatric medication management but are not a crisis center, emergency facility, detox program, or MAT (Medication-Assisted Treatment) provider. If you are experiencing a mental health crisis—such as suicidal thoughts or plans, hallucinations, or withdrawal symptoms—please call 911 or go to the nearest emergency room. * I acknowledge and understand Would you like to receive appointment reminders, health updates, and important information via email? Please indicate your consent below. Yes, I consent to receive email communications. No, I do not consent to receive email communications. Thank you!Your referral is being reviewed and a member of our staff will reach out with the next steps via phone or email provided.
