New Client Appointment Request

You’ll hear from us within 48 hours regarding your request.

You can also call 919-737-7797 to schedule.

Your Name (First & Last)

Your Phone Number

Your Email

How did you hear about us?

What type of therapeutic services are you seeking?

What is the primary reason for seeking services?

How do you prefer to join for your first session?

In-Person

Virtual

Your Address

Please give us details regarding your availability over the next week to help schedule your first appointment. Ongoing appointments will be schedule with your clinician.

When can you be available in the next week?

Mornings

Afternoons

Evenings

Share any specifics regarding availability or special requests

A credit/debit card is required to secure your appointment. The card will not be charged until the day of the appointment or your can pay in cash.

Card Number

Name on the Card

Expiration Date

Security Code

Billing Zip Code

I agree to receive communication from you regarding scheduling and understand and agree to your 48 hour cancellation policy for all scheduled appointments.

Signature

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