Detailed Intake Form

Caller name
Patient name
Date of birth
Phone * - (###) - ### ####
Address
Street Address

Address Line 2

City

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Email address *
Reason for appointment
Office location Asheville Cary Chapel Hill Concord Durham Raleigh Wake Forest Wilson
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Insurance type
Interested in: Therapy Medication Both Therapy and Medication Assessment for Trans* Medical Care Wellness Services Teletherapy All of the above
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