New Patient Intake Form

Taking this first step takes courage. Fill out the form below and our compassionate intake team will reach out within one business day to welcome you.

What to Expect

Response within 1 business day
Confidential & judgment-free
Insurance verified before first visit
Same-week appointments available
Telehealth options available
No referral required

Prefer to Call?

Our intake team is available Monday–Friday 8am–5pm.

(919) 224-6039

In Crisis?

If you are in immediate danger, please call 911 or text/call the 988 Suicide & Crisis Lifeline at 988. Do not use this form for emergencies.

Tell Us About Yourself

Fields marked * are required. Everything you share is confidential and protected by HIPAA.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Home Address

Emergency Contact Name

Emergency Contact Phone

Insurance & Payment

Insurance Provider

Member ID

What Brings You Here

Primary Concern *

Service or Program Interest

Current Medications

Previous Treatment History

Anything Else You'd Like Us to Know

Your information is protected by HIPAA and will never be shared without your written consent. By submitting, you agree to be contacted by our intake team.

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