315 E. Worthington Avenue
Charlotte, NC 28203
Phone: 704.335.6100
Fax: 704.335.4001

Your information is held in strict confidence. If you prefer, you can call our office directly (704-523-4881) to schedule an appointment or request information.

First Name:
Last Name:
Address/Street:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
E-mail:
Check here if you would like us to mail you a brochure:  
Comments/Questions:
Would you like to schedule an appointment?
Yes   No
Is there a specific therapist you would like to see?
Is there a particular day and time that works best for you?
If you plan to use your insurance for your counseling sessions please provide the following information:
Insurance Co. Benefits and Customer Service Phone #:
Insured Party:
Insured Parties Date of Birth:
Membership ID#:
Client (Person receiving counseling) Name:
Client Date of Birth:
How would you like us to contact you once we call to verify your benefits?
If you provide your insurance information we will call to verify your mental health benefits and e-mail or call you with the information we are given. You are encouraged to call as well to verify your benefits as it is your responsibility to know the limits of your plan and you will be responsible for any fees not paid by your
insurance company.

 

You will receive a response to your inquiry within 24 hours of your request.

This is for NON URGENT communications only and is a request for information in order to schedule an initial counseling session.  This communication does not constitute a counseling relationship and  counseling services can not be rendered through these communications.  If you are experiencing a crisis or situation that requires immediate attention please call 911 OR the Behavioral Health Call Center at 704-444-2400 OR proceed to your nearest Emergency Room.
 

4950 Park Road
Charlotte, NC 28209
Phone (704) 523-4881
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