Appointment Request

Please fill out the information below and a dedicated member from our team will reachout to you from the number 980-355-9494 or email within 24 hours to confirm your visit.

First name*

Last name*

Date of birth:*

Month

Day

Year

Email*

Phone*

Please tells us what made you reach out and what is most important for us to understand about your mental health needs:

I plan to pay by:

Insurance

Self-pay

Please upload a copy of your insurance card (front and back) so we can verify that we accept your plan.

File upload

I am interested in:

Medication management

Supportive therapy

Both

Still deciding

Which state do you live in?

This is the state you will physically be present at the time of your telehealth visit.

Please select your preferred appointment day and time:

Morning

Afternoon

Evening

Anytime

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday (if available)

How did you hear about us?

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature*

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Currently serving NC, WA, & CA.

Tel: 980-355-9494

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