Radical Healing Collaborative Appointment Request Form - Primary Care, Psychiatry and Other Medical Care

Radical Healing is excited to add more inclusive medical care providers. Appointments are available now for in person appointments in Durham or virtual telehealth appointments for residents across the entire state of North Carolina. To begin the onboarding process with us, please complete the following form. Someone will be in touch with you within a few days to set up your initial onboarding and intake paperwork.

Note: We are currently onboarding those with Blue Cross Blue Shield, Aetna, United Healthcare, Tricare, and Cigna insurance plans, and those who wish to be self-pay. We will begin onboarding those with Medcost in the coming months. Though we are now able to accept some Medicare/Medicaid insurance plans for medication management, please note that prescriptions will likely need to be for paid out of pocket. (Updated 5/6/2024)

First Name (Chosen) *

Last Name *

What are your pronouns?

Email *

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

Yes

Phone *

May we text you to provide updates on your appointment request? We will only text you if we cannot reach you via email. *

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

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

Are you a current therapy patient at Radical Healing? *

Yes

If yes, who are you working with at Radical Healing?

What concerns are you hoping to address in this appointment? *

Do you need an interpreter? If so, please let us know what language.

Date of birth *

Do you identify as LGBTQ+?

Do you identify as BIPOC (Black, Indigenous, Person of Color)?

I understand that I must reside in North Carolina to receive care. Clients of Haley Pittman must reside in either Florida or North Carolina to receive care. *

Yes

How did you hear about us?

Please list three times that you are available to speak on the phone regarding scheduling between the hours of 9-5 during the week (Monday through Friday) *

Insurance and Payment Information

Your legal name (used for insurance billing purposes only) *

Address (used for insurance billing purposes only) *

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

Do you need sliding-scale medication management? *

Yes

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

Primary subscriber date of birth

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

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