Name *

First

Last

Email *

Phone *

Brief description of what you would like help with so we can make sure we are a good fit for you. *

Type of client *

• New client
• Previous client

Which therapists are you wanting to schedule with? *

• Shannon Smith
• Kirsten Cole
• Taylor Kracht
• Aaron Yearwood
• Trent Morrow
• Brittany Preslar
• Maria Chase
• Marina Skrabalak
• Rebecca Wojciechowski
• Uyen Dinh
• Haleigh Kaufmann
• It does not matter

Insurance *

• Blue Cross Blue Shield
• Out of Network

Multiple Choice (If virtual you must be physically in NC at the time of the appointment due to license requirements)

• In person
• Virtual

How did you hear about us *

• Referral from doctor
• Internet search
• Word of mouth
• School counselor
• Marvin Ridge School Event or Banner
• Other

If you were referred by a doctor which practice referred you?

Submit