Request an Appointment
For scheduling needs, please call (919)635-6202. Please leave a voicemail or a text and we will return your call.
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Email *
What is the patient's name? *
Patient's Date of Birth
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Please provide a phone number for a return call. *
If the patient is a minor, please provide the name and contact # of a guardian.
Intake Visit Location Requested *
Do you require a refill for a controlled substance?
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Any concerns with intrusive thoughts of self harm?
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Recent Psychiatric Hospitalizations (within 1 year)
 *
Purpose of Visit
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What is your main concern?
Do you have Medicaid or Medicare?  (We are out of network and unable to provide care at this time. Please contact an in-network provider).
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What private insurance do you have?  (We are not in-network with Blue Home or UNC Health Alliance plans at this time).
 *
Please include your insurance ID and Group #
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Benefits quoted are not a guarantee of benefits. I understand it is my responsibility to understand my individual insurance benefits, if applicable.
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Required
Date Referral Submitted
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Referred by (answer only if referred by a provider)
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