JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Butterfly Counseling Patient Inquiry Form
Please fill this form out and we will be in touch!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Patient First Name
*
Your answer
Patient Last Name
*
Your answer
Patient DOB
*
MM
/
DD
/
YYYY
If the patient is a minor, please provide parent/ guardians name.
Your answer
Reason for needing therapy?
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
In-Person or Virtual
*
In-Person in our Lillington NC Office
Virtual
First Available
Preferred Time of Day for Appointments
*
Early to Mid Day (8:00am - 12:00pm)
Afternoon (12:00pm - 5:00pm)
Evening (6:00pm - 11:00pm) - Coming Soon!
Doesn't matter, I'm flexible
Insurance - If your insurance is NOT listed then we can offer a self-pay rate to be seen.
**Not all of our clinicians are paneled with all insurances listed**
*
BCBS
Medcost
Cigna
Contigo
Aetna
Tricare - There is a waitlist for Tricare insurance - A Self-Pay rate can be discussed
Campbell University Intern - $10 session - WAITLIST
Other - Self-Pay
Therapy Requesting
*
Children, Ages 3-12
Adolescents, Ages 13-17
Individual Adults, Ages 18+
Couples
Geriatrics
Family Therapy
Are you needing EMDR Therapy
Yes
Clear selection
Provider Request - if you want to see a specific clinician.
Your answer
Referred by
Your answer
Is it okay to text or email you?
*
Text is okay
Email is okay
Both text and email are okay
Please make sure you respond to someone when they reach out for a consult either by email or text. If you do not respond then we will remove you from our inquiry.
*
I Understand
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Butterfly Counseling, PLLC.
Report Abuse
Forms
