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Name*

First Last

Phone*

Email*

Name of person seeking services (if different from above)

First Last

Date of Birth*

MM slash DD slash YYYY

What type of service are you seeking?

IndividualCouples*AdolescentFamily

*Couples counseling is not always covered by insurance. Please discuss with your therapist and insurance company to clarify whether yours will be covered.

Do you have insurance?

YesNo

Insurance Carrier

BlueCross/BlueShieldMedCostAetnaCareSourceOther / Out-of-Network

Specify Insurance Carrier:

If Aspire does not accept your insurance plan, are you willing to go out of network for service?

YesNoI don’t know

Aspire is in-network with BCBS, Aetna, Medcost, Ambetter, and CareSource. To learn more about the benefits of out-of-network service, read this. To understand how to check your out-of-network benefits, read this.

To find a provider who is in-network with your insurance, visit PsychologyToday.com and search for a provider who accepts your insurance.

What days and times are you available for appointments?

Would you prefer in-person or online telehealth appointments?

In-person at Raleigh officeIn-person at Durham officeTelehealth (online)

Message

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions, appointment requests or messages to our practitioners. By sending, you agree that the phone number you provided may be used to contact you.

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