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 Legal Name (as it appears on your insurance card)

First NameLast Name
Preferred 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.)
Guardian's Name (if client is a minor)

First NameLast Name
List all parent(s)/guardian(s) that have custody or custodial rights as well as their phone number and email.
We understand that family dynamics and custody situations can look different for every family. We ask for information about other legal guardians so we can make sure we have the appropriate permissions and documentation needed to support your child’s care while protecting everyone’s privacy and rights. In North Carolina, biological parents are generally presumed to retain legal rights regarding medical and mental health decision-making unless legal documentation states otherwise.
Is there any court or legal documentation regarding custody for this client?
Custody Agreement

Please attach the most current documentation.
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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.
Do you have secondary insurance?
Location Preference
Which therapist do you prefer to work with?
Do you consent to text messages? We will only send messages directly related to you or your child's care
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? (ie. scheduling needs, therapist preferences, etc.)
Should be Empty: