Appointment Request Form

A person working at a desk with a laptop, a white coffee mug, and a green leafy plant in the foreground.

Name

First Name

Last Name

Phone Number

(###)

###

####

Message

Insurance

Specific plan

Setting

Service Requested

Referral Source

Please fill out out the information below. I will contact you within 2-3 business days to provide a free consultation or schedule your first appointment

If you are having a mental health emergency go to your nearest ER or call RHA mobile crisis available 24/7

RHA Mobile Crisis 1-844-709-4097

Link to regional hotlines here

Location

201 N Front Street Suite 513

Wilmington, NC 28401

Phone Number

910-523-2466

Fax number

( 910) 994-4870