Client's Legal Name:

First Name

Last Name

Client's Preferred Name/Chosen Name:

We recognize and honor that clients may use a name different from their legal name that we have to use for documentation and billing purposes. Please enter your nickname or chosen name here.

First Name

Last Name

Client's Sex:

We recognize and respect the importance of gender identity, but unfortunately the Simple Practice software is currently limited to only include male or female.

Preferred Pronouns:

Client's Date of Birth:

YYYY

Client's Email:

Client's Phone Number:

(###)

###

####

Address:

How did you hear about us?

Clinician's Name:

Who will you be working with?

First Name

Last Name

Session Location:

Where will you primarily be meeting with your therapist?

How will you be paying for sessions?

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]. Our practice is NOT in-network with: HealthyBlue, BCBS Blue Value, Blue Local, Blue Home, United, Tricare, Medicare and Medicaid. * Therapy with an Intern, Couples/Families, and Psychological Assessments are Self-Pay only. Individual Therapy -Initial Session (60-75 mins): $200 Ongoing Sessions (50-53 mins): $160 Couples/Family Therapy- Initial Session (60-75 mins): $230 Ongoing Sessions (53-60 mins): $200

I am a:

For insurance user's only:

Three Oaks Behavioral Health & Wellness

Mailing Address

Contact Us