Therapy Request Form

Please read before completing form:

If you are NOT interested in scheduling therapy and are only interested in medical services, please fill out this form instead: https://api.leadconnectorhq.com/widget/form/mgJIplOMeHfPoyLfJLVY
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.
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.
We accept Aetna, Cigna, United Healthcare, Tricare, and most BCBS plans except Blue Value, Blue Local, and Blue Home. We do not accept Medicaid or Medicare plans for therapy at this time.

Client's First Name (Legal) *

Client's First Name (Chosen)

Client's Last Name *

What are the client's pronouns?

Email *

Phone *

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? *

What days of the week/times is the client available for sessions? *

Briefly describe the issues you would like to work on in therapy *

Optional Information: Do you need support with any of 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.

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

Radical Healing also offers medical care! Would you like to be contacted for any of the following services?

Insurance and Payment Information

Full Legal Name of Primary Subscriber

Primary subscriber date of birth

What is the patient's relationship to the primary insurance subscriber?

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

Would you like to be a self-pay patient (i.e., NOT use insurance)? Please note that our self-pay rates are $250 for the intake session, then $155-185 per session depending on the licensure level of your assigned clinician. *

Picture of FRONT of Insurance Card

Picture of BACK of Insurance Card

Picture of Driver's License or Legal ID