RESPECT AND CURIOSITY
About Us
Our Practice
Our Therapists
Therapy Services
All Services and Fees
Group Therapy, Social Skills
CONTACT
Location
Schedule an evaluation
Are we accepting new clients?
Forms and Surveys
DIGITAL Client Forms
Cultural Competency Survey
Social Skill Therapy Group Surveys
Spanish Laguage
PRINTABLE Client Forms
Stuff Worth Reading
Community Resources
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
*
Health Insurance
*
Medicaid through Cardinal Innovations
Medicaid through Alliance BHC
Medicare
Bluecross Blueshield of NC
None of these
Check all that apply. This practice accepts Medicaid and Medicare only. You may file with private insurance as "out-of-network" (please check with your plan).
Submit
About Us
Our Practice
Our Therapists
Therapy Services
All Services and Fees
Group Therapy, Social Skills
CONTACT
Location
Schedule an evaluation
Are we accepting new clients?
Forms and Surveys
DIGITAL Client Forms
Cultural Competency Survey
Social Skill Therapy Group Surveys
Spanish Laguage
PRINTABLE Client Forms
Stuff Worth Reading
Community Resources
