Contact Us Name of Client (Minor) * First Name Last Name Pronouns (Client/Minor) Age/Date of Birth of Client (Minor) Name of Parent/Guardian * First Name Last Name Parent/Guardian's Email * Parent/Guardian's Phone Number * (###) ### #### Additional Contact Information (Email/Phone) If there is an additional parent/guardian/family member you would like us to communicate with, please share their contact info below. Preferred Contact Method Phone Call Text Email How did you hear about Three Oaks? Google Social Media Word of Mouth School/University Current Client or Employee Psychology Today Flyer/Business Card Other Who referred you for Psychological Testing? * Self Parent/Guardian Teacher/Professor Another Therapist Pediatrician/Doctor Psychiatrist Other 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 Other/Out-of-Network Self-pay What year in school is the client? * Please note we currently only assess individuals up to age 25. What school/university does the client attend? Has the client participated in an evaluation before? Yes No Preferred Office Location * Please note: we currently only offer assessments at our Apex office, but are looking to expand in the future. Your feedback is appreciated 🙂 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] What are the client's current areas of concern? Please select all that apply. * Academic skills and learning Behavioral (e.g., attention, hyperactivity, impulsivity, executive functioning, aggression, etc.) Cognitive abilities Emotional (e.g., anxiety, depression, emotion regulation, withdrawal, self-esteem, etc.) Early development and delays Language and communication Social skills and peer relationships Adaptive skills (e.g., self-care, daily routines, navigating school/community, etc.) Other concerns (Please describe in Message box below.) Are you (the parent/guardian) interested in learning more? Please check all that apply. Parenting strategies Psychotherapy services Community resources and related service providers (i.e., occupational therapy, speech-language therapy, physical therapy, tutoring, etc.) School-based supports (e.g., special education/IEP, Section 504 plan, intervention, specialized programs, etc.) Unsure/I am interested in learning more. (Please describe in Message box below.) Message Thank you! We have received your request. You should hear back within 3 business days.
