Mental Health Brief Intake Form

Brief Mental questions to get you started on your path to mental wellness
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Gender
Please list the problem(s) which you are seeking help?
Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoOther
Please upload a copy of your Drivers License.

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If using insurance, please upload a picture of the front of the insurance card.

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If using insurance, please upload a picture of the back of the insurance card.

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If you are using Insurace, we accept:

Aetna

Blue Cross/Blue Shield of North Carolina

Carelone Behavioral Health

Cigna

Oscar (Optum)

Oxford (Optum)

Quest Behavioral Health

United Healthcare (Optum)

The investment cost for those wanting to heal that are self-pay/cash pay are:

Initial Psychiatric Evaluation appointment (45 - 60 min): $250

Medication Follow-up appointment no therapy (20 - 30 min): $125

Psychotherapy Session (60 minutes): $150

Psychotherapy Session (30 minutes): $75

Combined Medication Follow-up and Psychotherapy Session (30 to 40 minutes): $150

Combined Medication Follow-up and Psychotherapy Session (40 to 60 minutes): $200

Therapeutic Support Group session (45 -60 minutes): $50
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Brief Mental questions to get you started on your path to mental wellness