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
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us?
Please Select
Google Search
Insurance Referral
Family/Friend
Community Event
Psychology Today
Do we have your consent to contact you back by phone and/or email? *Personal information collected, including phone numbers for SMS will not be shared with third parties or affiliates for marketing purposes
*
Please Select
Yes
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By checking this box, you agree to receive SMS messages from Carolina Counseling Wellness Associates for general scheduling inquiries and appointment reminders. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time or HELP for assistance
Yes I agree to receive SMS messages
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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