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Adult Inquiry Form
Thank you for reaching out! This form will give me a better idea of if I will be a good fit for you and your counseling needs. Please complete with as much detail as possible and I will get back to you within 48 hours.
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Email
*
Your email
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Preferred method of contact
*
Phone Call
E-mail
Text
No Preference
Would you prefer to meet in person or virtual?
In person
Virtually (You must be in the state of NC for all virtual sessions)
A mix of both, depending on schedule.
I am open to either
Clear selection
What brings you to counseling?
*
Your answer
Forms of payment:
*
Currently, I am contracted with the providers below. If you have another provider I am happy to provide superbill to submit for OON benefits.
I will be paying out of pocket
I have Aetna insurance benfits
I have BCBS insurance benefits
I have Medcost or CBHA insurance benefits
Required
What days are you available to meet?
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Send me a copy of my responses.
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