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Appointment Request Form

Appointment Request Form

Hi!  Please fill out this form to get started as a client with Peak Professional Group, PLLC
20Questions

HIPAA

Compliance

  • 1
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    Pick a Date
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  • 2
    Please select the option that best describes who this request is for.
    Please Select
    • Please Select
    • Minor
    • Adult
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  • 3
    For minors, please use their name here. We will get your information later in the questionnaire!
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  • 4
    Please tell us what relationship you have with the potential client:
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    • Potential Client
    • Parent/Guardian/Family Member
    • Professional
    • Other
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  • 5
    We will ask for the potential client's name and information soon!
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  • 6
    For professionals referring, please add your contact information below in case we have some follow up questions for you!
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  • 7
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  • 8
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 9
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  • 10
    This email address will be used for setting your account with us and sending any updates we may have on the appointment request.
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  • 11
    Please include the current grade and name of school.
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  • 12
    If not, please provide the name and contact information for the person who is able to legally sign consents for treatment on the next page.
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    • Yes
    • No
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  • 13
    Name, Phone No. &/or Email. If there is more than one parent in the home, feel free to add their information here as well. If there is another parent who does not live in the home, we will ask about that in the question.
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  • 14
    Name, Email & Phone No.
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  • 15
    This is only required in cases of shared custody
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 16
    If you do not have a primary care doctor, please state so below:
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  • 17
    Please Select
    • Please Select
    • Yes
    • No
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  • 18
    Please Select
    • Please Select
    • Yes
    • No
    • I don't know
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  • 19
    Please click on the correct insurance below. Please note that insurance information is for the client or potential minor client.
    • Aetna
    • Alliance Healthcare
    • Amerhealth Caritas
    • Blue Cross Blue Shield
    • Carolina Complete Health
    • Cigna/Evernorth
    • Healthy Blue
    • Oxford
    • Optum
    • UMR
    • United Community Plan
    • United Healthcare
    • Tricare/Humana Military
    • Wellcare
    • Vaya Health
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  • 20
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  • 21
    Please Select
    • Please Select
    • Yes
    • No
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  • 22
    Insurance name, subscriber ID, etc..
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  • 23
    In order to verify your identity & insurance information, please upload a copy of your Drivers License/State ID and the front and back of your insurance card here! If you are unable to upload using this form, please send them to our HIPPA-compliant email- support@peakprofessionalgroup.com
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 24
    If you need to give us more specific scheduling instructions, you can do this on the next page!
    • AM only (9am-11am)
    • Lunchtime only (11am-1pm)
    • Afternoon only (2pm-5pm)
    • Evening only (5pm-7pm)
    • I am flexible
    • Weekends
    • Other
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  • 25
    In order to streamline our scheduling, it will be helpful to tell us more about your scheduling preferences including specific days and times during the week when you are available for on-going sessions!
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  • 26
    We offer therapy in our Apex and Sanford locations, via telehealth or at Chatham & Wake Co. Schools
    • Online (telehealth only)
    • In-Person Only (Apex office)
    • In-Person Only (Clayton Office)
    • In-Person Only (Sanford Office)
    • School-based Therapy Program (Chatham Co. Schools)
    • I am flexible
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  • 27
    • Individual therapy
    • Couples therapy
    • Family therapy
    • School-based Therapy Program
    • I need help deciding
    • I am interested in multiple services
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  • 28
    For School-based Therapy Requests only
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  • 29
    We will do our best to match your requests but please know that we are not always able to do this so if it is not a major issue, please select "No Preference".
    • Female
    • Male
    • No preference
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  • 30
    • Alajah Fitchpatrick- Clinical Intern
    • Amber Opperman, LCSWA
    • Antonia Verhine, LCSW
    • Ashley Moore, LCMHCA
    • Cindy Hickman, LCMHC
    • C.Desiree Walls, LCMHC
    • Crystal Waddell, LCSWA
    • D'nise Williams Braswell, LCSWA
    • Douglas Farias Mariano, LCSW
    • Elliot Case, LCMHCA
    • Erika Hoeckberg, LCSW
    • Heather Easley, LCSWA
    • John Murphy, LCMHC
    • Joanne Lisa, LCMHC
    • Julianne Evans, LCMHCS
    • Key Burns, LCMHCA
    • Kristen Glees, LCMHC
    • Laurie MacDonald, LCSW
    • Laurie Nicholson, LCMHC
    • Leah Beckmann, LCSW
    • Madi Reynik, LCSWA
    • Margaret "Pendy" Payne, LCSW
    • Matt Morano, LCMHC
    • Max Kirn, LCSW
    • Melodye Ranyak, LCMHC
    • Rachel Middaugh, LCMHCA
    • Samantha Linton- Clinical Intern
    • Samantha Mahon, LCMHCS
    • Samantha Mellor, LCSW
    • Sarah Thomas Mariano, LCSW
    • Stephanie Coble, LCSWA
    • Yohance Tate- Clinical Intern
    • I need help deciding!
    • My provider isn't listed
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  • 31
    This will help us determine the best match for you!
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    While we will do our best to use your preferred method of contact, email is the most efficient way we are able to reach out. Be sure to check your Spam or reach out if you don't hear back from us within a few days!
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  • 34
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  • 35
    • New Lead
    • Insurance Verified
    • Sent to Provider
    • Pending Client Response
    • Pending Provider Response
    • Intake Scheduled
    • Need more Info
    • Added to TN Prospective
    • Client Portal Sent
    • Provider Unavailable
    • Waitlisted
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