Become a Patient — Tri-Cities Peace and Healing, PLLC

Take the First Step to Getting Help

Compassion, Caring, Kindness

Patient First Name

Patient's Last Name

Contact Person (If different from patient.)

Contact Person's Relationship to Patient

Patient's Date of Birth

MM

DD

YYYY

Patient Insurance Plan

Mobile Phone

SMS Permission

Yes, I give my express written consent to receive text (SMS) messages from the staff of Tri-Cities Peace and Healing, PLLC (a dba of The Office of Daphane Miller, PLLC) at the mobile number provided. Consent to receive messages is not a condition of receiving treatment. Text STOP to 423-534-9195 to cancel. Msg & data rates may apply.

Home Phone

Office Phone

Email

Therapy Notice

I understand Tri-Cities Peace and Healing does not provide talk therapy.

SPRAVATO®

I found you through the SPRAVATO® website.

Do you have any questions?

If you have a crisis or emergency, please call 911 or proceed to your nearest emergency room.

Please provide the information below, and we’ll contact you to schedule your appointment.

Please use this form to contact us about something other than setting up an appointment.

You can also call us at (423) 534-9195, Tuesday - Friday, 8 AM - 7 PM (Eastern).

NOTE
We only provide medication management. If you also need therapy, please get in touch with your insurance company for a referral.