First Appointment Request Form | Pine Rest Outpatient Services

To schedule your first outpatient appointment, call 866.852.4001 or use the appointment request form below.

If you have questions about outpatient services at Pine Rest, please call our Central Access at 866.852.4001. We are available 8 a.m. to 6 p.m. Eastern Time (ET), Monday – Friday except for major holidays.

For after-hours emergencies, please call the Pine Rest Contact Center which is staffed 24/7 at 616.455.9200 or 800.678.5500.

Outpatient Initial Appointment Request Form

Please fill out the information below and staff from our scheduling department will contact you within 48 business hours to set up an initial appointment.
Patient Information
Legal Name of Patient * Required
First Last
Patient's Date of Birth * Required
Parent/Guardian Name (if applicable)
First Last
Email
Name of Contact Person * Required
First Last
Phone Number * Required
Services Requested
Please indicate the type of services for which you would like an appointment (check one or more boxes below). Scheduling staff will be able to answer questions to help you determine which appointment type is best for you.
I would like to set up an appointment for: * Required
- Psychotherapy/Counseling (depression, anxiety, substance abuse, insomnia, behavior change, personality disorder, relationship issues, stress management, etc.)
- Psychological Testing (ADHD, learning disability, autism, brain injury, dementia, pre-surgical testing, etc.)
- Psychiatry (medication evaluation and/or management)
- Substance Use (assessment to determine level of care needed--outpatient, intensive outpatient, partial hospitalization, sub-acute detox)
- Telehealth (therapy sessions via a secure video conferencing application using your phone/computer/tablet)
Preference regarding clinician (if any)
Gender, age, etc.
Preference regarding clinic location (if any)
Insurance Information
Please provide your insurance information so that we may partner you with a provider who participates with your insurance.
Primary Insurance Company * Required
Primary Insurance Policy Number * Required
Insurance Subscriber Name * Required
First Last
Contact Information
The scheduling department is available to call between 8:00 AM and 5:00 PM Monday through Friday. Please provide your name, phone number and convenient times for our staff to contact you.
I prefer to be contacted on the following day(s):
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
I prefer to be contacted during the following time(s)
- 8 AM to 11 AM
- 11 AM to 2 PM
- 2 PM to 5 PM
Additional Contact Information
Thank you for your interest in scheduling outpatient services with us. Staff will contact you based on the contact information that you have provided above. If you are in need of immediate medical attention, please call our Contact Center which is staffed 24/7 at (800) 678-5500.

To schedule your first outpatient appointment, call 866.852.4001 or use the appointment request form below.

For after-hours emergencies, please call the Pine Rest Contact Center which is staffed 24/7 at 616.455.9200 or 800.678.5500.

Outpatient Initial Appointment Request Form

Patient Information

Services Requested

Insurance Information

Contact Information

If you have any questions, please call 866.852.4001.