Online Referral Form

Please fill out this form completely, press the SUBMIT buttom at the bottom, and the Scheduling Coordinator will return your call within 24-48 hours.

You may also call our main office, at 919-401-8090, in order to get more information or schedule an appointment.

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Patient Information

First Name *

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone *

Email Address

Date of Birth

Age

GenderMaleFemaleNon-binaryPrefer not to Answer

Legal Guardian (if applicable)

Relationship to client (if applicable)

Referral Source (if applicable)

Insurance Information

Insurance CarrierBlue Cross Blue ShieldCignaTricareMedicareAetnaSelf-Pay

Policy Number

Services

Court Related?YesNo

Services Requested

Psychological EvaluationSubstance Abuse AssessmentCustody EvaluationReunification TherapyIndividual TherapySubstance Abuse CounselingParent CoordinationSupervised VisitationGroup TherapyIn-home TherapyCase ManagementDevelopmental TherapyPsychiatry Consult/Medication Management

Presenting Problem(s) and Referral Questions

Scheduling Preferences, Requests, or Concerns

Submit Referral Form