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 Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Guardian's Name (if client is a minor)
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Insurance Provider
Please Select
Aetna
Blue Cross Blue Shield
United Health Care
Oscar
Ambetter
Wellcare Medicaid
VAYA
Healthy Blue
United Health Care Community
Amerihealth Caritas
Medcost
Self Pay
Other
If your insurance provider isn’t listed above, that means we are not in network for your plan. We do offer self-pay sessions on a sliding scale. If you’d 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
*
Asheville
Hendersonville
Waynesville
Virtual/ Telehealth
Equine Therapy
*
I do NOT consent to receiving text messages and will only communicate via email with Your Next Chapter.
You can text me.
Submit
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