Request an Appointment

top of page

Use tab to navigate through the menu items.

Potential Client's First Name

Is the potential client a minor?

Yes

No

Email

Date of Birth of Potential Client

What services are you seeking?

What are your goals for treatment?

Potential Client's Last Name

Parent/Guardian's First and Last Name

Phone

Insurance

How did you hear about us?

Anything else you would like us to know?

Thanks for submitting!
We’ll get back to you shortly.

Phone: 850-988-9431 · Fax: 850-792-2491 · info@thctally.com

Subscribe to receive our newsletter

Email

Thanks for subscribing!

You have the right to receive a Good Faith Estimate of what your services may cost.

bottom of page