Radical Healing Collaborative Appointment Request Form - Medication Management

Radical Healing is excited to add more inclusive psychiatric medication management providers. Appointments are available now for in person appointments in Chapel Hill 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 and Aetna insurance plans, and those who wish to be self-pay. We will begin onboarding those with United, Cigna, and Medcost in the coming months. (Updated 11/15/2023)

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.

If you are requesting services for a dependent who is a minor, please list (1) their name, (2) their pronouns, (3) your relationship to them (e.g., parent, grandparent), and (4) if you are an existing patient with the Radical Healing Collaborative.

Are you a current therapy patient at Radical Healing? *

Yes

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

Date of birth *

Do you identify as LGBTQ+?

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

Do you have preferred identities held by a provider (e.g., gender, race)?

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

Yes

How did you hear about us?

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 or pro-bono (free) medication management? Please note: We will begin offering services on a sliding-scale in mid-October. *

Yes

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

Do you have multiple forms of insurance?

Picture of FRONT of Insurance Card

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Picture of BACK of Insurance Card

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Picture of Driver's License or Legal ID

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