Brain Well
Services
Conditions
About
- About Paradise
- Our Providers
Resources
Contact

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

2. Have you used any of the following in the past month: Cocaine, Ecstasy, Methamphetamine, Heroin, Inhalants, Non-Prescribed Pain Killers *

Yes

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

Yes

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

5. How old are you? (We are currently unable to accept minors.) *

0 - 17 years old

18 years old + above

First Name *

Last Name *

Mobile Phone *

Email *

Preferred Method of Communication

Text
Call
Email
No elements found. Consider changing the search query.
List is empty.

Date of Birth *

Sex Assigned at Birth *

Male

Female

Street Address *

City *

State *

Postal Code *

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
No elements found. Consider changing the search query.
List is empty.

How did you hear about us? *

Google
Facebook or Instagram
Referred by my provider
Referred by family or friend
Dr. Damayo
Webinar or Event
Millennium Health - Dr. Mark Gordon
Podcast
Other
No elements found. Consider changing the search query.
List is empty.

How will you be paying for your visits? *

Insurance
Self-pay (credit/debit card)
No elements found. Consider changing the search query.
List is empty.

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
No elements found. Consider changing the search query.
List is empty.

Primary 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

Upload a photo of the front of your Driver’s License or Other ID card

Upload a photo of the front & back of your Insurance Card(s)

I Consent to Receive SMS & Email Notifications, Alerts & Occasional Marketing Communication from Paradise Behavioral Health. You can reply STOP to unsubscribe at any time.

Captcha

Become a Patient

EXPLORE

CONTACT

Leave a Google Review

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