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 email or contact you back by phone?
*
Please Select
Yes
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please give us the email address you would like us to send your intake consent forms to
*
example@example.com
We offer in-person and virtual appointments. Please let us know which you prefer.
Please select how you plan to pay for your appointments. We accept BCBS PPO, Aetna PPO plans, State Health Plans (SHP), and our private pay options start at 100$ per session
*
Please Select
Aetna PPO
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 can help you decide.
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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