Contct Form

FINE PRINT: Before completing this form, please consider that the information is not encrypted to ensure confidentiality. We will not share your information with anyone, and it is unlikely that someone will access it; however, once you send this message it leaves your computer and enters a World Wide Web of computers over which neither you nor we have control; it is in theory available to be read by the system administrators of Internet Service Providers. By contacting us through this form you are indicating that you understand these limits to confidentiality.

If you are experiencing a mental or behavior health emergency, please call 911, go to your closest emergency room, or contact your nearest crisis resource, which can be found at http://crisissolutionsnc.org/

Please complete the form below and we will contact you shortly

* Indicates required field

Your Name *

First

Last

Child's Name (if applicable) *

First

Last

Birthdate of Client (may be the child) *

Phone Number *

Email *

Referred by: *

Reason for appointment *

Please Choose Your Preference *

Telehealth (video or phone conference) In-person (COVID precautions in place) Unsure/Either

Health Insurance *

To meet with a therapist as soon as possible, are you available to meet on weekdays, between 9AM - 3PM? *

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