Let's Get Started
Getting started with one of our providers is easy. Begin completing this initial questionnaire and we'll reach out to schedule your first appointment. If we're unable to guide you, we'll help you with referrals.
General Demographic Information
Please provide your First and Last Name.
Please let us now what you'd like to be called.
Please provide your preferred email addres.
Please provide your current age.
Example: 124 Main Street, Anywhere, NC 12345
Please select from the options below:
Please provide a copy of your insurance card
Please provide a copy of your DL or goverment issued ID. (Telehealth laws require that clients be in the state where the provider is licensed.)
Clinical Related Questions
Please list your preferred provider. We intend to your honor your preference if your preferred provider is accepting new patients.
Are you on any controlled substance medications (e.g., Xanax, Klonopin, Valium, Ativan, pain pills, Ambien, Adderall, Ritalin, Vyvanse)?
Have you ever been hospitalized for a psychiatric emergency?
Do you have a history of suicide attempts?
Do you have any active addiction to alcohol or drugs?
What psychiatric medications are you currently taking? Please list the NAME, DOSE, PURPOSE, and PRESCRIBER for each. If not currently taking psychiatric medication please write "none".
Please use this space to provide any additional relevant details (e.g., if you're requesting couples or marriage counseling, you might want to provide your partner's name, email, and phone number.)
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