Radical Healing Referral Requests
We will do our best to connect you with a therapist who is good fit for your needs! Please complete this form to the best of your ability. Feel free to call and/or text us if that feels more accessible for you. Call or Text us at 919-238-1120.
What is your name?
What pronouns do you use? (ex. they/them, she/her, he/his, all pronouns)
What is your phone number?
What is your email address?
Do you prefer a phone call, email and/or text? Can we leave a voicemail? (please select all that apply) *
Required
Do you identify as LGBTQ+?
Clear selection
Do you identify as BIPOC?
Clear selection
Do you have a preferred therapist or identities held by a therapist?
Preferred model of therapy, if any?
Briefly, what is bringing you to therapy now?
When are you available to meet for sessions? Do you have any scheduling needs we should know about? (e.g. only available on weekends or evenings, reliance on public transportation)
Do you plan to use insurance (if so, who is your insurance provider and what plan do you have)? Self-pay? Full fee? Sliding scale?
If sliding scale, how much can you reliably and reasonably afford to pay for each session?
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