Full Name of the Client
*
First Name
Last Name
Client's Date of Birth
*
/
Month
/
Day
Year
Date
Current Date
-
Month
-
Day
Year
Date
Age
Parent/Guardian Name
First Name
Last Name
E-mail
*
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How did you hear about us?
Please Select
ARC Partner
Direct Mailer
Doctor/PCP
Email/Newsletter Campaign
Friends and Family
Google Search
Insurance Referral
Insurance Website
Mental Health Provider
Psychology Today
School/University
Social Media
Webinar/Community Event
Other
Who can we thank for the referral?
Please select the service(s) you are interested in:
Therapy Services
Please Select
Individual Therapy
Couples Therapy
Family Therapy
Reunification Therapy
Co-Parenting Therapy
Other (Please briefly describe)
None Needed
Evaluation Services
Please Select
Psycho-Educational Evaluation (ADHD, LD, Giftedness, Executive Functioning)
Autism Spectrum Disorder (ASD) Evaluation
Kindergarten Readiness Evaluation
Psychological Evaluation (NOT for court)
Adoption Readiness Evaluation
Career Assessment
Immigration Evaluation, Hardship
Immigration Evaluation, Medical Disability Exception (Form N-648)
Forensic Psychological Evaluation (of one person; can be for family, civil or criminal court)
Custody Evaluation (of whole family; for family court)
Parental Capacity Evaluation (of one person; for family court)
Other (Please briefly describe)
None Needed
Psychiatric Medication
Please Select
Psychiatry for a CHILD (Medication, under age 18)
Psychiatry for an ADULT (Medication, age 18 or older)
None Needed
Other services not listed above; or additional information you'd like us to know
My preferred location is:
Please Select
Tele-health (online video chat)
Durham in-office only (also convenient for Chapel Hill clients. near the Southpoint Mall)
Durham in-office preferred, telehealth OK if best fit and availability
Raleigh in-office only
Raleigh in-office preferred. telehealth OK if best fit and availability
My preferred appointment time is:
Please Select
Mornings
Afternoons
Evenings
Saturdays
Upload Front of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
(optional) Upload Driver's License
Browse Files
Drag and drop files here
Choose a file
Cancel
of
utm_source
utm_source
utm_campaign
utm_term
utm_content
Submit Now
Clear All Answers
Should be Empty: