ABC Wellness Group
About Us
Services
Medication Management
Medication Assisted Treatment (MAT)
NeuroStar TMS Therapy
Psychotherapy
Suboxone
Medical Marijuana
Referral Form
Contact
Patient Portal
Contact Us
402 W 8th St, DeRidder, LA 70634
(337) 401-4686
(337) 419-0974
abcwellness@abcwlgrp.com
Patient Referral Form
Interested in becoming a patient? Fill our our referral form to start the intake process!
Fill Out Form
Patient Portal
Patient Portal
Visit our patient portal to fill out forms and check your medical records.
Have a question?
Send us a message! We’ll respond as soon as possible.
Note: we prefer calls for questions regarding our clinical services or intake process. If you are having an emergency, please call 911.
Contact Form
Name
Email
Message
SEND
Referral Form
Phone Intake Form
Patient Information
Date
First Name
Last Name
Phone
Email
Date of Birth
Parent or Guardian
Address
Address Line 1
City
State
Zip Code
Appointment Communication Preferences
Text
Phone
Email
Referred By
Service Requested
Medication Management (M.M.)
Psychotherapy (PTX)
Transcranial Magnetic Stimulation (TMS) Evaluation
Suboxone/Medication Assisted Treatment (MAT)
Medical Cannabis Evaluation
Briefly Describe Reason for Services
Insurance Information
Insurance Type
Medicare
Medicaid
Tricare
Commercial
Other
If other, please specify:
Primary Insurance
Effective Date
Member ID Number
Group Number
SUBMIT
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