Name *

First Name

Last Name

Phone *

(###)

###

####

Are you seeking individual therapy or another service? *

Individual therapy

Consultation (Clinicians/Organizations)

Group Healing

Speaking Engagements

Have you previously worked with a therapist?

Yes

No

What are your main areas of focus or concerns in therapy?

Anxiety

Depression

Trauma

Relationships

Stress

Family Dynamics

Other (please specify)

Are you interested in telehealth or in-person sessions? *

Telehealth

In-person (Raleigh, NC)

Either

In terms of cost, what will you be using for coverage?

Blue Cross Blue Sheild

Aetna

Aetna State Health Plan

United Health Care

Cigna

Self-pay

Sliding Scale