Name *

First Name

Last Name

Phone (optional)

(###)

###

####

What payment option works best for you to access counseling? *

BlueCross BlueShield of North Carolina

Aetna

Superbill for an out of network insurance plan

Private Pay

What is your availability for scheduling recurring appointments? *

8-10am

10-12pm

12-1pm

1-4pm

4-7pm

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business. *

I understand that electronic forms of communication should not be used to discuss therapeutic content and/or request assistance for emergencies. Please only include necessary information concerning your appointment needs or general questions. If you opt to utilize electronic forms of communication to discuss therapeutic content, there is no guarantee of absolute confidentiality.