Appointment Request Form
Please fill out the following HIPAA compliant referral form to connect with Brianna about starting counseling services. Referral requests will be responded to by the end of the next business day.
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Email *
First & Last Name *
Are you seeking services for yourself or for someone else (ex. child, spouse, friend)? *
If you are seeking services for someone else, please enter their name here and fill out remaining identifying information for them
Preferred Name
Date of Birth *
Gender Identity (cis female, male, trans, gender nonconforming, etc) *
Personal Pronouns *
Phone Number *
Email Address *
Address *
What's bringing you to seek support? *
What days/times would you prefer to schedule appointments? *
Do you prefer in person sessions or telehealth sessions? Our office is located in downtown Raleigh *
Who would you prefer to see? *
How did you find out about Half Moon Mental Health & Wellness? *
If referred by another provider, please list them below
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