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 *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Sex *
Gender
Your answer
Phone number *
Your answer
Email *
Your answer
Street Address *
Your answer
City, State *
Your answer
Zip Code *
Your answer
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
Your answer
Policy Holder Name (Primary) *
If you are not using insurance fill this form with N/A
Your answer
Policy Holder Date of Birth (Primary)
MM
/
DD
/
YYYY
Relationship to insured (Primary)
Insurance Carrier (Secondary)
Your answer
Insurance Policy Number (Secondary)
Your answer
Policy Holder Date of Birth (Secondary)
MM
/
DD
/
YYYY
Legal Guardian (if applicable)
Your answer
Relationship to Client
Your answer
Referral Source *
Primary Care Physician, Insurance Provider, Psychology Today or other online referral source, Family/Friend, Church, Self, etc.
Your answer
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.
Your answer
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.
Your answer
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