Primary Care, Psychiatry, Physical Therapy, and Other Medical Care Appointment Request Form

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 *

What are your pronouns?

Email *

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

Yes

Phone *

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.

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

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

Other Services

Radical Healing also offers therapy - are you interested in being connected with a therapist?

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...

How would the client like to receive services?

In-Person Only

Telehealth Only

Open to Both

Do you have a preferred provider?

What days of the week/times are the client(s) available for sessions?

Please briefly describe the issues you would like to work on in therapy.

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