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Brain Well
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Become a Patient

BECOME A PATIENT

Submit the form below and our team will review your application and contact you with next steps.

New Patient Application

1. Have you had auditory, visual hallucinations or paranoid thoughts in the past week? *

Yes

No

2. Have you used illicit drugs in the past month? *

Yes

No

Please indicate which substances you have used within the last month and the most recent date of use.

3. Have you abused alcohol in the past month? *

Yes

No

How many drinks do you have on a typical day?

4. Have you had a suicide attempt or engaged in self-harm in the past two weeks? *

Yes

No

5. Are you 18 or older? (We currently do not accept minors.) *

Yes

No

First Name *

Last Name *

Mobile Phone *

Email *

Date of Birth *

Sex Assigned at Birth *

Male

Female

Address

Street Address *

City *

State *

Country

Country

Postal Code *

Primary Insurance *

Aetna
Beacon
Blue Cross / Blue Shield
Cigna
Commercial
Compsych
Government Other
Humana
Medicare
Supplemental
Tricare
United Healthcare
Web TPA / Lee Health
Wellcare
None or Self-Pay
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Insurance ID

Secondary Insurance

Aetna
Beacon
Blue Cross / Blue Shield
Cigna
Commercial
Compysch
Government Other
Humana
Medicare
Supplemental
Tricare
United Healthcare
Web TPA / Lee Health
Wellcare
None
No elements found. Consider changing the search query.
List is empty.

Secondary Insurance ID

How did you hear about us?

Google
Facebook or Instagram
Referred by my Provider
Referred by a Friend
Webinar or Event
Dr. Damayo
Millennium Health - Dr. Mark Gordon
Podcast
Other
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Reason for Visit *

Addiction
ADHD
Anxiety
Brain Well
Dementia
Depression
Eating Disorder
Genetic Testing
Hormonal Imbalance
Med Management
Psych Evaluation
Traumatic Brain Injury (TBI)
Therapy / Counseling
TMS
Other
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Upload Front & Back of ID Card (Driver’s License or Other) *

Upload Front & Back of Insurance Card(s)

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Become a Patient

EXPLORE

Meet Our Providers

New Patient Info

Telemedicine Support

CONTACT

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Office: 941-347-8341

Fax: 941-347-7702

25097 E Olympia Ave. Suite 201

Punta Gorda, FL 33950

Office Hours

Monday - Thursday:

9am-12pm & 1pm-5pm

Friday - Sunday: Closed

SUPPORT

If you need immediate support:

National Suicide Prevention Hotline: Call 988

Crisis Text Line: Text HOME to 741741

HIPPA COMPLIANT | Paradise Behavioral Health

HIPPA COMPLIANT | Paradise Behavioral Health

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