NEW PATIENTS CALL:
919-929-9610
TOLL FREE:
877-876-3783
INTAKE FORM

Please fill out this form and someone will call you back within one business day. If you have also placed a call to the Intake Line at 919-929-9610, please indicate it in the "Reason For Seeking Services" field so that we do not attempt to contact you twice.

Type of Service *

Choose Standard to see a psychiatrist, or therapist in person. Choose Teletherapy if you'd like to skype in with a therapist(not covered by insurance). Choose Wellness Center Services for Massage, Natruropathic, and other complimentary Services.
Client's Name * First Last
Contact Person's Name First Last
Date of Birth * / MM / DD YYYY
Daytime Phone * - (###) - ### ####
Please give the best phone number to be reached during business hours.
Email *
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Reason for Seeking Services *

Please give us a quick overview of the reason you are currently seeking services, your history and any medications that you are currently on. The more detailed you are, the faster we can find a health provider and appointment for you.
Type of Insurance (*Only required if you plan to file claims to your insurance company.)
Preferred Location *
Best Time to Receive a Call During Business Hours
How Did You Hear About Us?

Intake Form

Intake Form