Client Name: *

Please note: If you are entering information on behalf of a child or teen, please list their information.

First Name

Last Name

Best Contact Phone Number: *

(###)

###

####

Please check any additional areas you are willing to be seen at:

Raleigh

Chapel Hill

Durham

Garner

Apex

Telehealth

Pittsboro

Scheduling Preferences *

Select all that apply.

Morning

Midday/Lunch Hour

Early Afternoon

Early Evening

Weekend [Limited Offerings]

Will you be using insurance? *

All Three Oaks clinicians are in-network with Aetna, Evernorth (formerly known as Cigna) & Blue Cross Blue Shield including all PPO plans, Blue Advantage, Blue Select, Blue Care, Classic Blue, Blue Options, NC State Health Plan, Blue Federal, and Out of State BCBS PPO plans. We also accept the [North Carolina State Health Plan]. Additionally, we are able to bill out-of-network with other major insurance companies. Our practice is not in-network with: HealthyBlue, BCBS Blue Value, Blue Local, Blue Home, United, Tricare, Medicare and Medicaid. * Therapy with a Clinical Intern, Couples, Families, and Psychological Assessments are Self-Pay only.

Insurance

Self-Pay

Reduced rate with a Clinical Student Intern