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 Berry - Steven Taylor Berry, PMHNP-BC Dryden - Bailey Dryden, PMHNP-BC Link - Kylie Link, PMHNP-BC Wiseman - Tiffany Wiseman, PMHNP-BC Name of Patient * First Name Last Name Date of Birth * MM DD YYYY Phone * Country (###) ### #### Email * Can we send you text messages at this number? * Yes No Can we leave you voicemails at this number? * Yes No Do you have health insurance? * Yes No I'm not sure Choose your health insurance provider (if available). Aetna BlueCross BlueShield Cigna Magellan Optum Tricare UnitedHealthcare VA Community Care Network Self Pay 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 Prefer not to answer 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 for your appointment request. Please check your email for a scheduling confirmation from Blueprint Telehealth (noreply@tebra.com) and follow the instructions to confirm your appointment.
