Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *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 clientPrevious clientWhich therapists are you wanting to schedule with? *Shannon SmithKirsten ColeTaylor KrachtAaron YearwoodTrent MorrowBrittany PreslarMaria ChaseMarina SkrabalakRebecca WojciechowskiUyen DinhHaleigh KaufmannIt does not matterInsurance *Blue Cross Blue ShieldOut of NetworkMultiple Choice (If virtual you must be physically in NC at the time of the appointment due to license requirements)In personVirtualHow did you hear about us *Referral from doctorInternet searchWord of mouthSchool counselorMarvin Ridge School Event or BannerOtherIf you were referred by a doctor which practice referred you?Submit
