Online Referral Form
Please fill out this form completely, press the SUBMIT button at the bottom, and the Scheduling Coordinator will return your call within 24-48 hours.

Note: This information is transmitted to our office in a secure manner.

You may also call the main office, at 919-418-1718, ext. 101, in order to get more information prior to scheduling an appointment.
Client Name *
Date of birth *
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DD
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Sex *
Gender
Phone number *
Email *
Street Address *
City, State *
Zip Code *
Primary Insurance Carrier *
Please note: If you do not see your insurance carrier listed we are not in network and will need to discuss other payment options.
Insurance Policy Number (Primary) *
If you are not using insurance fill this form with N/A
Policy Holder Name (Primary) *
If you are not using insurance fill this form with N/A
Policy Holder Date of Birth (Primary)
MM
/
DD
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YYYY
Relationship to insured (Primary)
Clear selection
Insurance Carrier (Secondary)
Insurance Policy Number (Secondary)
Policy Holder Date of Birth (Secondary)
MM
/
DD
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YYYY
Legal Guardian (if applicable)
Relationship to Client
Referral Source *
Primary Care Physician, Insurance Provider, Psychology Today or other online referral source, Family/Friend, Church, Self, etc.
Services Requested *
Required
Presenting Concerns and Referral Questions *
Briefly describe what brings you to seek services at this time. This information will assist us in placing you with the most appropriate clinician.
Scheduling Requests or Preferences
Describe any preferences you may have for a specific clinician, time of day, or day of the week. We also will try to accommodate any spiritual or cultural preferences as well.
Submit
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