Contact Us
Your Name
*
Client's Name, if different than above
Client's Date of Birth
-
Month
-
Day
Year
Date
Email Address
*
Phone Number
How do you prefer to be contacted?
*
Email
Phone call
Text message
No preference
Which location are you inquiring about? Select all that apply.
*
Hendersonville
Asheville
Telehealth
Please indicate what type of insurance you have or if you are interested in self-pay.
*
Ex.: BCBS, Aetna, United, etc.
Please indicate any clinician preference.
How did you hear about us?
Word of mouth
Facebook
Google
Physician's office
School-based
Drive-by
Other
Message (What's the reason you are seeking counseling, what are you looking for, etc.? Please include any information that may help us connect you with a provider who is a good fit.)
*
Submit
How do you prefer to be contacted?
Email
Phone call
Either one
Phone Number
-
Area Code
Phone Number
Should be Empty: