Radical Healing Collaborative Appointment Request Form - Primary Care, Psychiatry, Physical Therapy, 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 appointment and intake paperwork.

Note: We are currently onboarding those with Blue Cross Blue Shield (including Healthy Blue effective 3/1), Aetna, United Healthcare (including the Community Plan), Tricare, Medcost, and Cigna insurance plans, and those who wish to be self-pay. (Updated 2/27/2025)

Client's First Name (Chosen)

Client's First Name (Legal) *

Client's Last Name *

Are you an established medical care patient looking to schedule a follow up appointment?

Yes

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? *

May we leave you a voicemail message? *

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

What times of the day tend to work best for you for appointments?

7am-9am

9am-11am

1pm-3pm

3pm-6pm

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

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 services? *

Yes

If you're planning to use insurance, please select your provider below.

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