New Client Registration Form - Urban Healing Counseling
Thank you for your interest in working with Urban Healing Counseling PLLC! We appreciate your interest in working with our office.   

We accept BCBS/ Anthem, Aetna, and Cigna/ Evernorth. We also accept private pay clients and have a limited number of affordable rates slots. If you would like for us to verify your insurance coverage also complete this form:  Insurance Verification Form (google.com) (in addition to this form).

It may take up to 5 days to respond to your inquiry. We do I very best to respond in a timely manner. If you have any questions or concerns please email us at admin@urbanhealingcounseling.com. 

If you are experiencing a mental health crisis or if you are currently experiencing suicidal ideations, please do not complete this form. Instead, call 911 or go to the nearest emergency room.

By completing this form you give us consent to email you. 

Thank you. 
Sign in to Google to save your progress. Learn more
Email *
Full Name: *
Name of Guardian (if you have a legal guardian)
Phone Number:
Date of Birth:
MM
/
DD
/
YYYY
State of Residence (we only treat clients that reside in North Carolina, you must be in NC at the time of session) *
I am a
Clear selection
What is the best time of day for appointments? You may choose multiple: *
Required
What are the best days of the week for you? You may choose multiple: *
Required
Which therapist(s) are you interested in? If you choose multiple, our administrative team will explore your schedule and needs further to help you find the best fit. *
Required
Do you wish to use Insurance to cover your sessions?  If you are using insurance and would like for us to verify your coverage please complete the "Insurance Verification Form".  *
Have you ever attended therapy before?
Clear selection
Have you ever been hospitalized for mental or emotional reasons? *
Is this court ordered therapy?
Clear selection
What issues are you struggling with? Choose all that apply. *
Required
Why are you seeking therapy? (Please elaborate in 1-3 sentences)
How did you hear about us? *
Insurance Verification Form 
Kindly note that Urban Healing Counseling PLLC is currently only in network with Blue Cross Blue Shield, Cigna and Aetna. If you do not have insurance there is no need to complete this form, email the front office at admin@urbanhealingcounseling.com for options. If you have an insurance that we do not accept there is no need to complete this form, we do not bill out of network claims. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Urban Healing Counseling PLLC.

Does this form look suspicious? Report

Google Forms