Appointment Request Form

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Today's Date
Date
Month
Day
Year
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Is this request for: Please select the option that best describes who this request is for.
Please Select
Please Select
Minor
Adult
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What is the name of the potential client?For minors, please use their name here. We will get your information later in the questionnaire!
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What is your relationship to the potential client?Please tell us what relationship you have with the potential client:
Please Select
Please Select
Potential Client
Parent/Guardian/Family Member
Professional
Other
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Name of Person Completing this FormWe will ask for the potential client's name and information soon!
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Professional Contact InformationFor professionals referring, please add your contact information below in case we have some follow up questions for you!
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What is your (or potential client's) Date of Birth?
Date
Month
Day
Year
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Country
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Phone Number* This field is required.
Please enter a valid phone number.
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Please add the email address where you would like us to communicate updates:* This field is required.This email address will be used for setting your account with us and sending any updates we may have on the appointment request.
example@example.com
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Where does the minor attend to school?Please include the current grade and name of school.
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Do you have legal guardianship of the minor?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.
Please Select
Please Select
Yes
No
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Name & Contact Information of Primary Parent/Legal Guardian: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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Please add the contact information of the secondary parent/guardian.Name, Email & Phone No.
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Please upload a copy of guardianship papers below:This is only required in cases of shared custody
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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What is the name and phone number of your (or potential client's) primary care doctor?If you do not have a primary care doctor, please state so below:
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Do you have insurance that you will be using for therapy services?
Please Select
Please Select
Yes
No
18
Is your insurance Medicaid?
Please Select
Please Select
Yes
No
I don't know
19
What insurance do you (or potential client) have?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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What is the subscriber ID?
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Do you (or the potential client) have more than one insurance policy?
Please Select
Please Select
Yes
No
22
Please add any secondary insurance information below:Insurance name, subscriber ID, etc..
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Identification Card & Insurance CardIn 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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When are you (or potential client) available on a regular basis for scheduling therapy sessions?* This field is required.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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Please add any specific scheduling instructions below: 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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Which service location do you prefer?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 (Sanford Office)
School-based Therapy Program (Chatham Co. Schools)
I am flexible
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What type of service are you requesting?
Individual therapy
Couples therapy
Family therapy
School-based Therapy Program
I need help deciding
I am interested in multiple services
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Name of School for requested serviceFor School-based Therapy Requests only
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Would you prefer a male or female clinician?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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Who would you like to see at the practice?
Antonia Verhine, LCSW
Alicia Blankenship, LCSW
Ashley Moore, LCMHCA
Cindy Hickman, LCMHC
C.Desiree Walls, LCMHCA
D'nise Williams Braswell, LCSWA
Drew Hutchins, LCMHCA
Don Sanders, LCMHC
Douglas Mariano, LCSWA
Elena Rael, LCSW
Erika Hoeckberg, LCSW
John Murphy, LCMHC
Joanne Lisa, LCMHC
Julianne Evans, LCMHCS
Kennedy Pagliari, LCSW
Key Burns, LCMHCA
Kristen Glees, LCMHCA
Laurie MacDonald, LCSW
Laurie Nicholson, LCMHCA
Leah Beckmann, LCSW
Matt Morano, LCMHC
Max Kirn, LCSW
Melodye Ranyak, LCMHC
Margaret "Pendy" Payne, LCSW
Rachel Middaugh, LCMHCA
Samantha Mahon, LCMHCS
Samantha Mellor, LCSW
Sarah Thomas Mariano, LCSW
Stephanie Coble, LCSWA
I need help deciding!
My provider isn't listed
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Tell us a little about what is going on and how we can help support you (or potential client)This will help us determine the best match for you!
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Is there anything else that you would like us to know about you or your situation?
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What is your preferred method of contact?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!
Email
Text
Phone call
Flexible
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Status
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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Verify Benefits Link
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Theranest Log in
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Samantha Mahon, LCMHCS
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