Appointment Request

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Appointment Request

This appointment request will be sent to our General Mailbox. If you know which counselor you would like to request, you will receive a faster response by submitting an appointment request directly from that counselor's profile page on our website. Upon submission of this form, a member of our clinical team will reach out within 24-48 hours for a phone consultation and scheduling.

Email *

Location Preference

Durham

Greenville

Holly Springs

New Bern

Raleigh

Virtual Sessions

Wake Forest

Counselor Preference *

First and Last name of person completing this form: *

Phone number of person completing this form: *

Relationship to client: *

Self

Parent/Guardian

Client first and last name (if different from person completing this form):

Client date of birth *

YYYY

Please provide a brief description of your counseling needs: *

What are you looking for in a counselor? *

How did you hear about our practice? *

If this appointment request is for couples therapy, please list your partner's First and Last Name, Date of Birth, Email Address, and Phone Number below. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.

If this appointment request is for family therapy, please list below the following for every family member age 18+ who will be participating: First and Last Name, Date of Birth, Email Address, and Phone Number. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.

If this appointment request is for a minor client (under age 18) who is a child of separated/divorced parents in which both parents must consent to services, please list the First and Last Name, Date of Birth, Email address, and Phone Number of other parent. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.

The insurance companies below are the ones with which we are considered IN-NETWORK. Please specify which insurance company below covers your mental health benefits. If you have a different insurance provider other than these or are uninsured, please choose "None of the above/Self-Pay." PLEASE REFERENCE THE BACK OF YOUR INSURANCE CARD WHEN ANSWERING THIS QUESTION, as your mental/behavioral health benefits may be outsourced to an insurance company that differs from the one that manages your health benefits. PLEASE NOTE: Couples Counseling, Family Counseling, and Biblical Counseling are considered "self-pay" services, as they are not billable to insurance. See our FAQ for Couples and Family Counseling for more information. *

Aetna

Blue Cross Blue Shield: CHOOSE THIS OPTION ONLY IF YOU HAVE ONE OF THE FOLLOWING PLANS: PPO, Blue Value POS, Indemnity, Blue Care HMO, Blue Home with Novant Health, Blue Home with UNC Health Alliance, Blue High Performance Network (HPN) Duke, BCBS Federal, BCBS Student Blue)

Cigna (Miriam Selph, Will Dees, and Joy Tanner only)

Medcost (Will Dees, Courtney Hayes, Ashley McMahen, Jocelyn Dixon, Rachel Schwager only)

Tricare non-network providers (April Lovelace, Will Dees, and Courtney Hayes only) - we will provide a superbill for you to file with Tricare for reimbursement

None of the above/Self-Pay

If you are not the primary policy holder, please list the primary policy holder's first/last name, their date of birth, and their relationship to you:

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