Name * First Name Last Name Pronouns Email * Phone * (###) ### #### Preferred Contact Method Phone Call Text Email How did you hear about us? Google Facebook/Instagram Doctor/Therapist Flyer/Business Card Word of Mouth Current Employee Current Client School/University Other If you were referred by a doctor/therapist, please list their name below. Preferred Office Location * What is your preferred office location? Based on the specialties & availability of our clinical team, we will do our best to link you with a therapist at the office site you prefer. Downtown Raleigh [A] East Raleigh [A] West Raleigh [A} North Raleigh [A} Midtown [A] Garner [B] Knightdale [B] Virtual [B] Chapel Hill [B] Apex [C] North Durham [C] South Durham [C] Southern Village [C] Pittsboro [C] Office Location(s): Secondary Preferences Insurance * We do NOT currently accept Blue Home, Blue Value, United, Medicaid or Medicare. We are in-network with BCBS (PPO plans), Evernorth (formerly Cigna), & Aetna. We also accept the NC State Health Plan and EAPs. Additionally, we are able to bill out-of-network with other major insurance companies. Please visit our FAQ page to learn more about billing & insurance. Blue Cross Blue Shield Evernorth (formerly Cigna) Aetna EAP Self-pay (I will not be using insurance) Other/Out-of-Network Scheduling Preferences Please describe any calendar restrictions, or let us know if you have a preferred meeting time. Based on the availability of our clinical team, we will do our best to link you with a therapist who has openings during your preferred schedule. We will be better able to connect you with your preferred therapist if there is flexibility within your calendar preferences. Would you be open to scheduling virtually? Yes, I am open to scheduling virtually. No, I am not open to scheduling virtually. Have you been in therapy before? * Yes No Have you participated in EMDR therapy before? * Yes No What are you hoping to work on with EMDR? * Message Thank you! We have received your request. You should hear back within 3 business days.
