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. 204, in order to get more information prior to scheduling an appointment.
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Client Name *
Date of birth *
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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.
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