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New Patient Request.docx (DOCX — 31 KB)
Enrollment request is initiated by emailing and not calling us. The New Patient Request document should be completed, then emailed to our office at clinicalstaff@ymail.com. This document is editable only to insurances Dr. Islam is a provider with (if you do not see your insurance please read the following note.).

*NOTE: Your mental health insurance may differ than what is on your card, if this is the case check the back of your card to see if there's a different company listed or contact your insurance provider for clarification.  For example: At times United Health Care may use Value Options, BCBS (through HEB), or Compsych, etc.

Once we have received your request we will confirm receipt. Dr. Islam will then review your request, and then we will contact you if we have additional questions or to schedule. Please make note that when approved our office requires a one time new patient fee of $75.00 which is refunded to you at the time of your appointment for the difference of your copay.

























New Patient Request.pdf (PDF — 430 KB)

If you have complications with the word document, here is a PDF form of the document. Please follow the same procedure as listed above.

This is a multi step process.  We do not treat Chemical Dependence.  Patients who need immediate medical or Psychiatric care need to go to the nearest urgent care facility and not apply here.
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