New Patient Referrals

New patients can be referred to Agape Youth Behavioral Health by any Primary Care Provider, Medical Specialist, or Therapist.  New patient referrals can be faxed to 423-464-7510.  They must include the reason for referral, types of services requested, patient information, insurance information, and any other pertinent information.  Our standard referral form is linked below.  We evaluate referrals on a case-by-case basis and will try to respond within 1 week of referral.

New Patient Referral Form

For New Patients

Once you have been accepted as a new patient to our clinic, you may download and complete our New Patient Pack of forms (linked below). Also if you are a patient of Dr. Michelle Fast, you may download and complete the Policies Form (linked below).   These should be completed prior to your appointment.  You can bring them with you to the initial appointment or fax them ahead of appointment to 423-464-7510.  Please also download and review our Privacy Practices.

New Patient Pack – All Forms

Attn: Dr. Fast Patients Only – Policies Form

Privacy Practices

If your child was referred concerning ADHD or you are concerned about ADHD, the Vanderbilt Assessment Forms can be downloaded and completed.  While these are not required for the initial appointment, they can be helpful.  Please have both a parent/caregiver and a teacher complete the respective forms.

Vanderbilt Assessment Forms

Payment of all co-pays, co-insurance, and deductible amounts owed is expected at the time of service.  You will be provided with an estimated amount owed at check-in.  Depending on circumstances, Agape Youth Behavioral Health will occasionally agree to payment plans for services.  If requested, please download and complete the following form:

Agape Payment Plan