Contact Us CONTACT US Do not use this form to contact us if you feel that you are in crisis or experiencing an emergency. Call 911 or go to the nearest emergency room. This form should only be used to contact us for general questions. Name* First Last Email* PhoneDo not include any confidential or private information in your message below.Subject*What areas do you believe should be the focus of your therapy?*We are only providing online services at this time. Are you open to teletherapy?*We are only providing online services at this time. Are you open to teletherapy?YesNoPlease list any days/times that do NOT work for you to schedule weekly or bi-weekly therapy appointments.*Are you open to private pay/out-of-network benefits?*Are you open to private pay/out-of-network benefits?YesNoIf you wish to work with a therapist who is in your insurance network, who is your insurance carrier?*If you wish to work with a therapist who is in your insurance network, who is your insurance carrier?N/A--I plan to private pay and not use in-network benefits.AetnaBCBS or BCBS State PlanBlue Local or Blue ValueCarolina Behavioral Health Alliance (CBHA)CignaUnited Healthcare or OptumCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
