Consultation Form for Therapy Services
Thank you for inquiring about our services at Renewed Resilience, PLLC. I am currently accepting new clients. Please complete the following form to confirm interest in beginning therapy. You will be contacted by phone within 24-48 hours of completion. If this is an emergency, please contact 988 or your local emergency services.
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Email *
Legal Full Name *
Parent/Guardian Name (if under 18). 

Type N/A if this does not apply. 
 *
I understand that parental participation in the initial phone consultation and intake is required for all minors (under the age of 18). I understand that parents will be provided with periodic updates on child's engagement throughout therapy.  *
Preferred Email *
Is is safe for us to send an email to this address? *
Preferred Phone Number *
Is is safe for us to call or text this number? *
Are you located in NC or VA? We are currently only licensed to provide services in these two states. *
Renewed Resilience is an online practice. Are you okay with receiving therapy via HIPPA compliant video service? *
Renewed Resilience is in network with some commercial insurance plans . What insurance/payment plan would you like to utilize for your services?

**Please note that we do not accept the following:
Medicaid/Medicare 
Care First/BCBS
FEP Blue Plans
 *
What problems would you like to address during therapy? *
Required
Renewed Resilience will have availability Mondays -Thursdays. Please select your availability. *
Required
How did you learn about my services? *
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