• Name*
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• Phone*
• Email*
• Name of person seeking services (if different from above)
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• Date of Birth*
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• What type of service are you seeking?
  IndividualCouplesAdolescentResilience Coaching*Family

• *Please note that Resilience Coaching is not covered by insurance..

• Do you have insurance?
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• Insurance Carrier
  BlueCross/BlueShieldMedCostBright HealthAetnaOther / 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

• 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 telehealth appointments?
  In-personTelehealth
• If in-person, which office location do you prefer?
  RaleighLake JohnsonDurham
• 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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