Request a New Appointment

Please complete the following form to initiate counseling services.

Wake Counseling is in-network with BCBS, Aetna (commercial & State health plans), Ambetter & UHC.

Email *

This appointment is for *

Client's First Name *

Client's Last Name *

Client's Date of birth *

Phone *

Couples Therapy: Name of your partner/spouse *

Child Counseling: Name of both parents or legal guardian(s). Also, provide documentation for custody, if applicable, otherwise we are not able to schedule an appointment. *

Email of partner/both parents/legal guardian(s) or referring source *

Phone number of partner/both parents/legal guardian(s) or referring source *

Address

Street Address *

City *

State *

Postal code *

Legal Sex

Female

Male

Other

What is the best time to contact for scheduling?

9:00 am - 12:00 pm

1:00 pm - 3:00 pm

3:00 pm - 5:00 pm

What is the best method to contact?

Phone Call

Text Message

At which location(s) would you prefer to be seen? You can select more than one option *

Do you have any current or previous history of suicidal thoughts or suicide attempts, or other self-harming behaviors (ex. cutting, eating disorder, substance abuse)? *

Yes

Do you have any history of recent or previous hospitalization for mental health or substance use? Are you being mandated by court or CPS for services? Are you seeking services for Social Security/Disability determination? Are you seeking services to receive ESA (emotional support animal) letter? Are you seeking services solely for medication management? *

Yes

Do you have any other special requests or accommodations (ex. location, specific therapist request, special needs, accessibility issues, etc.)?

Insurance Information

Clients must call their insurance company to verify outpatient therapy benefits; we will send claims to your insurance and cannot be held responsible if services are not covered

If you will be using insurance, what type(s) of insurance do you have? (we are only in network/accept the ones listed below-we are no longer in network with Cigna) *

Blue Cross Blue Shield (BCBS)/Anthem

Aetna or State Health Plan (SHP)

United Healthcare (UHC)/Optum/UMR

Ambetter of NC

I do not have insurance or have a plan not listed above (Self-Pay)

Other

Subscriber Number * For BCBS plan, include 2-digit suffix with your member ID *

Primary Subscriber's date of birth (required for couples & child therapy)

Copy of your insurance card (front & back) or driver's license for self-pay clients. We must have this information prior to scheduling your initial appointment. Call our office at 919-647-4600 if you need any assistance.

Front of the card *

Back of the card *

By checking this box, I consent to receive messages related to my account or services I have requested. These messages may include appointment confirmation, reminders, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply STOP to opt-out.