Request an Appointment

Appointment Request Form

* Indicates required field

First and Last Name (of Client) *

First

Last

Date of Birth (of client) *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Insurance *

Subscriber ID *

If BCBS What State is the plan from? *

General Appointment Availability *

MORNINGS AFTERNOONS EVENINGS NO PREFERENCE

Please mark all that apply.

Do you have a day of the week that you prefer? *

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY No Preference

Please select the days that you prefer for your counseling sessions. We will make every effort to accommodate your request

Which office would you like to come to? *

Apex Office Telehealth School-based Program (Chatham County only)

What service do you need/want? *

INDIVIDUAL COUNSELING (ADULT) INDIVIDUAL COUNSELING (CHILD/ADOLESCENT) COUPLES COUNSELING FAMILY THERAPY I NEED HELP DECIDING

Do you know who you would like to see? *

Please select a name from the menu below and we will do our very best to accommodate your request.

Tell us a little about what is going on.... *

Please tell us a little about what is going so that we can match you with the best provider in our practice!

Additional Information *

If there is any other information that we need to know about you, feel free to add it here!

Submit