Radical Healing Collaborative Appointment Request Form - Therapy

Please read before completing form:

The Radical Healing Collaborative recognizes that a well aligned clinical match increases the likelihood of a positive therapy experience. We do our best to connect clients to a clinical match that can support their current needs and aligns with any preferences. In order for us to help our team achieve a more aligned match for your needs, please respond to the questions on this form as honestly and thoroughly as you can. Please note, more information may be requested for clarification and to ensure we can meet your requests.
Please note, a clinical match is not guaranteed. There are many factors including but not limited to: availability or speciality areas of care that may inform an appropriate connection to therapy at RHC. If we are unable create an appropriate clinical match for your needs within our practice, we will provide you with resources to accessible community support and can help you navigate connecting to alternate community care.
We are only able to offer weekly appointments at this time. Sessions may be moved to biweekly at the discretion of the therapist once care is established.
Our therapists are only available to provide care for clients who are residing in North Carolina due to state licensure restrictions.
Many of our clinicians have waitlists for new patients.
We accept Aetna, Cigna, United Healthcare, and all BCBS plans except Blue Value, Blue Local, and Blue Home. We do not accept Medicaid or Medicare.

If you or someone you know is experiencing mental health emergency, please consider using any of the below crisis resources:

Hotlines:

The Trans Lifeline at 877-565-8860
Blackline at 800-604-5841 (prioritizes BIPOC callers)
The Samaritans Hotline at 877-870-4673
The National Domestic Violence Hotline at 800-799-7233

In-Person Crisis Resources:

Your nearest emergency room, or any of the below:
Carolina Outreach Behavioral Health Urgent Care 919-251-9009 (Durham County)
Durham Recovery Response Center 919-510-9132
Triangle Springs 919-372-4318 (Raleigh/Durham)
Pasadena Villa 877-845-5235 (Raleigh/Charlotte)
Wake County Crisis Stabilization Center 984-974-4800 (Wake County)
Holly Hill Respond 919-250-7000 (Wake County)

Client's First Name (Legal) *

Client's First Name (Chosen)

Client's Last Name *

What are the client's pronouns?

Email *

We will be reaching out to you via email and text. Please confirm your understanding by checking yes. *

Yes

Phone *

May we leave you a voicemail message? We will only call if we cannot reach you via email. *

I am seeking services for... *

Myself (18 or older)

My partner(s) and I (relationship therapy)

A minor who is my dependent

Family therapy

I am seeking... *

If you are seeking relationship therapy, please list the full name of your partner(s) and their email address.

Please complete the following section for yourself or if you are a legal guardian, your dependent minor.

Client Date of birth *

Does the client identify as LGBTQ+? *

Does the client identify as BIPOC (Black, Indigenous, Person of Color)? *

What are the client's racial and ethic identities?

Asian

Asian American, Native Hawaiian, and Pacific Islander (AANAPI)

Bi/Multiracial

Black/African American

Indigenous/Native American/First Nations

Latin/Latin@/Latine/Latinx

Southwest Asian and North African (SWANA)/Middle-Eastern

White/European American

How would the client like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Would you like the first available clinician or would you like to work with a specific clinician? *

Does the client have preferred identities held by a therapist (e.g., gender, race)?

Briefly describe the issue you would like to work on. *

Optional Information: Do you need support with any other the following: self injurious behavior, thoughts of harm, disordered eating patterns, or substance use? This will help us to ensure that we can find the best clinical match to meet your needs.

What are your preferred therapy models, techniques and/or approaches (e.g., cognitive behavioral therapy, trauma-informed, feminist)?

I understand that a commitment to weekly sessions is required to establish care. *

Yes

I understand that I must reside in North Carolina to receive care. *

Yes

If you have accessibility needs (e.g., a wheelchair-accessible building), please state them here.

Provide 3 Times The Client Is Available for Counseling *

How did you hear about us? *

Insurance and Payment Information

Full Legal Name of Primary Subscriber

Primary subscriber date of birth

If you're planning to use insurance, please select your provider below. We currently accept BCBS, Aetna, United Healthcare, and Cigna. We do not accept Medicaid or Medicare.

Would you like to be a self-pay patient (i.e., pay out of pocket for services?) *

Do you have multiple forms of insurance?

Picture of FRONT of Insurance Card

Picture of BACK of Insurance Card

Picture of Driver's License or Legal ID