Appointment Request for Carolina Counseling Wellness Associates
Please fill out this information to get started. Our client care coordinator will be in touch soon to help you get scheduled and answer any questions you may have.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Do we have your consent to contact you back by phone and/or email?
*
Please Select
Yes
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provide the email address you would like us to send your intake consent forms to. (Please check your spam folder.)
*
example@example.com
We offer in-person appointments and virtual appointments. What is your preference?
*
Please Select
High Point- NC
Clayton -NC
Virtual - (statewide NC resident)
Please select how you plan to pay for your appointments. We accept BCBS PPO, Aetna PPO plans, and Aetna State Health Plans (SHP). Our private pay options start at $100 per session
*
Please Select
Aetna PPO or Aetna State Health Plan (SHP)
Blue Cross Blue Shield PPO
Private-Pay
Which provider are you requesting an appointment with? (leave blank if you are unsure) Our client care coordinator will match you with an available provider.
If you are scheduling a request for treatment of a minor child or family member, please enter their name and date of birth here:
Please let us know a little more about what you are seeking counseling for. (just a brief reason, so we can help get you matched with the best provider for you)
*
Please upload your insurance card here if you plan to use insurance for your appointments
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