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Urban Healing Counseling, PLLC New Client Registration Form
If you are interested in therapy with Urban Healing Counseling, PLLC please complete this from (if you prefer a phone consult, please email us at
Date of Birth
Have you ever received therapy before?
Have you ever been hospitalized for mental or emotional reasons?
Why are you seeking therapy? ( 1-3 sentences)
What time of the day are you typically available for appointments? You may choose multiple.
Early Afternoons ( 12-4pm)
What days of the week are you typically open for appointments? You may choose multiple.
What therapist would you like to book with? (take a look at our bios)
It does not matter
What issues are you struggling with?
Self- Esteem / Worth
What type of insurance do you have if you do have insurance ?
BCBS - Blue Cross, Blue Shield
United / Optum
I do not have insurance
The ONLY insurance that Urban Healing Counseling is in network for/ accepts is Blue Cross/ Blue Shield (BCBS). If you would like to use your BCBS benefit please provide us with the subscriber ID?
What is your BCBS group number?
Is the insurance in your name?
If your coverage is not in your name, please provide us with the person's name it is in and date of birth( your mother, father, spouse, etc)?
If you are using insurance/ BCBS it may take up to two weeks for us to verify your coverage. Option 1: You may wait until we verify your coverage to book an appointment. Please book an appointment for two weeks out if you choose this option. Via email you would be notified what your copay is Option 2: Book an earlier appointment and pay $50, we will verify your insurance and advise you of your co pay. If your co pay is lower than $50, will reimburse you or we will keep a credit on file for you to use for future appointments. We will file your insurance and tell you your copay 7 days after your first appointment. Please check "Yes" if you understand aforementioned statement.
N/A I am not using BCBS/ Insurance
Payment policy. Payment is accepted at the time of service or before. You will be invoiced and expected to pay to pay the invoice. You may also pay at the time of your appointment with cash. You understand this statement.
How did you hear about us?
Therapy for Black Girls
A current client
Online google search
Thank you for completing the form. You may now book here: https://square.site/book/1D28AZ549Y8XW/urban-healing-counseling-pllc-raleigh-nc Link to membership site for intake paperwork: https://www.urbanhealingcounseling.com/blank
Please do not submit this form if you are experiencing a mental health crisis or if you are currently experiencing suicidal ideations, please call 911 or go to the nearest emergency room.
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This form was created inside of Urban Healing Counseling PLLC.