Online Doctor Appointment Form

Self Referral

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Have you ever applied to our facility before?*

YesNo
Are you in need of any translation services? If so, what type (Examples: American Sign Language, Spanish, French, Etc.)?
Who is your Insurance Provider?*
If you have another insurance other than what is specified please list it below.
Do you give us permission to reach out via text message to coordinate care?*
Type of Peer Support*

Mental Health Peer Support (includes mental illness, emotional stress, trauma, etc.)Co-Occurring Peer Support (Mental Health & Substance Use)Forensic Peer Support (Criminal Justice Involved)Other
Reason for Support (Must select at least 2 of the following)*

Educational & Vocational SupportCommunity Integration & Resource SupportHousing & Self-Advocacy SupportSocial, Cultural and Spiritual Development SupportSelf-Maintenance, Recovery and Wellness SupportOther
Online Referral is NOT for crisis situations. (required) ☐ I acknowledge and understand that submission of a referral is not for crisis situations. If you are in crisis, please call 911. If you need assistance for a mental health crisis, please call or text the Suicide and Crisis Lifeline at 988 or 800-273-8255, or the NC Peer Warmline at 855-PEERS-NC (855-733-7762).
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Self Referral