To receive counseling simply fill out the form below and someone will reach out to you within 48 business hours. If you need assistance in filling out your referral please call (704) 537-7775.
Patient First Name
Patient Last Name
Type of Insurance
Choose an option
Psychology for All
Blue Cross Blue Shield
Parent or Guardian Contact information if patient is under 18
What is the reason for counseling?
Referral Source Name (if applicable)
Referral Source Email (if applicable)
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