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Appointment Request Form
Please fill out the following HIPAA compliant referral form to connect with Brianna about starting counseling services. Referral requests will be responded to by the end of the next business day.
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Email
*
Your email
First & Last Name
*
Your answer
Are you seeking services for yourself or for someone else (ex. child, spouse, friend)?
*
Myself
Someone else
If you are seeking services for someone else, please enter their name here and fill out remaining identifying information for them
Your answer
Preferred Name
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender Identity (cis female, male, trans, gender nonconforming, etc)
*
Your answer
Personal Pronouns
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Address
*
Your answer
What's bringing you to seek support?
*
Your answer
What days/times would you prefer to schedule appointments?
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Morning (8:30am-12:00pm)
Afternoon (12:00pm-4:00pm)
Evening (4:00pm-6:00pm)
Required
Do you prefer in person sessions or telehealth sessions? Our office is located in downtown Raleigh
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Telehealth
In Person
Who would you prefer to see?
*
Brianna Hicks, LCMHC (Waitlist: 6-8 weeks for new clients; 3-4 months for sliding scale appointments)
Marley Toben, LCSW
How did you find out about Half Moon Mental Health & Wellness?
*
Google Search
Social Media (Facebook, Instagram, etc)
Psychology Today
Referred by a provider in the community
Referred by a current Half Moon MHW client
Other:
If referred by another provider, please list them below
Your answer
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