Detailed Intake Form

Caller name

Patient name

Date of birth

Phone * – (###) – ### ####

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Email address *

Reason for appointment

Office location AshevilleCaryChapel HillConcordDurhamRaleighWake ForestWilson

How did you hear about us?

Insurance type

Interested in: TherapyMedicationBoth Therapy and MedicationAssessment for Trans* Medical CareWellness ServicesTeletherapyAll of the above

Opt-out of CPMH mail listOpt-out of Goldenseal mail list