New Client Contact Form

New Client Contact Form

Thank you for reaching out. Please note, we are not capable of providing crisis services at this time. If you are experiencing a mental health crisis, please call 911 or reach out RHA Mobile Crisis at (888) 573-1006.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the client under 18? (Please note that after-school appointments are first come first serve and prioritized to established clients.)*

YesNo
Guardian's Name (if client is a minor)

First NameLast Name
List all parent(s)/guardian(s) that have custody or custodial rights.
Is there any court or legal documentation regarding custody for this client?

Yes- If a custody agreement exists, we require a copy of the current court order prior to beginning services. You can email a copy to info@yournextchaptercounseling.comNo
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Insurance Provider
If your insurance provider isn’t listed above, that means we are not in network with your plan. If you have secondary insurance, we must be in network with both plans in order to bill your benefits. We are not able to accept Medicare plans of any type at this time.We do offer self-pay sessions on a sliding scale. If you would like to use out-of-network benefits, we are happy to provide monthly superbills that you can submit to your insurance for possible reimbursement.
Location Preference*

AshevilleHendersonvilleWaynesvilleVirtual/ TelehealthEquine Therapy
Which therapist do you prefer to work with?

Unsure; I would like the referrals coordinator to match me with someoneAbby FeykaAshley HayesAshlyn BridgewaterAudrey PhilbrickBecca GaunchBrandon WhitesideCatherine MorrisonChelsea SinkovichCaitlin RileyDerek MartinezElide Gonzalez-PerezEliza PaulEthan St. JohnEmmi LohrentzHannah KupsovHope HinsonHunter WaldropGray SwartzelJaclyn FarleyJoey BaneKatie BaileyKrysten RichardsonKyla Van ZylLee ShepardMadison KluttzSamantha MorganSarah Broughton
*

I do NOT consent to receiving text messages and will only communicate via email with Your Next Chapter.You can text me.
Please tell us why you are seeking therapy at this time. Please share as much as you feel comfortable with, this helps us ensure we match you with the right therapist.*
Is there any additional information you would like the referrals coordinator to know?
Should be Empty: