Wellness Partner Inquiry Form 
We look forward to partnering with you on your mental wellness journey. Please complete one form for each individual requesting service.
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Email *
Today's Date: *
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Name of person completing form: *
What service are you interested in? *
Name of person(s) to receive services  (First and Last name) if different than person completing form (type N/A if non applicable): *
Date of Birth *
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Age *
Enter your current North Carolina address including the city, state and zip code: (Email a copy of your state Driver's License, Government ID or other verification of residency to admin@cedartreeempowerment.com) *
Phone number: *
Do you give us permission to leave a voice message if a phone call is warranted during the intake process? *
What is especially troubling you lately? *
Have you been to therapy before? *
If yes, please provide as much information about your experience as possible. If no, type N/A *
What would you like to accomplish with online therapy? *
Have you ever experienced any thoughts of self harm or harming someone else? If you are currently in crisis or need to speak with a clinician immediately due to self harming or homicidal thoughts, please contact the National Suciude Hotline at 1-800-273-8255. *
If yes, please provide dates and give brief explanation. If no, type N/A *
How often are you interested in a 50 minute session? (Recommendations will be provided in first session based on presenting concerns) *
What is your availability for session day and time? *
Insurance or Private Pay? (Sliding scale options may be available) *
If utilizing insurance, provide insurance company name? If not, type N/A *
How did you hear about us? If you were referred by an individual or entity, please provide the name. *
You will be matched with a therapist according to your need. However, please feel free to indicate the name of the therapist you are interested in. Check out our team here if you have not already: https://cedartreeempowerment.com/meet-the-team/ *
Signature (Print Full Name) and Date: *
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