Client Name: * Please note: If you are entering information on behalf of a child or teen, please list their information. First Name Last Name 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. Pronouns 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. Male Female Client Birthdate: * Are you a current or previous Three Oaks client? * Yes No Which service are you interested in receiving? * Child therapy (0-12) Teen therapy (13-17) Individual adult therapy (18+) Couples therapy (no primary client) Family Therapy (no primary client) If you are entering information on behalf of the client: Your first & last name, and relation to client Best Contact Email: * Best Contact Phone Number: * (###) ### #### Preferred Contact Method Phone Call Text Message Email How did you hear about us? * Google Facebook/Instagram Word of Mouth Doctor/Therapist Flyer/Business Card Podcast If you were referred by someone, please list their name below: Please choose your preferred therapy format: * Telehealth In-Person For Telehealth: In which state do you reside? Please choose your desired office location: * Apex Chapel Hill- Cloister Downtown Raleigh Garner Midtown Raleigh North Durham North Raleigh East Raleigh West Raleigh Pittsboro Chapel Hill- Southern Village South Durham Telehealth/Virtual Please select any other areas you are willing to travel to: Raleigh Chapel Hill Durham Garner Apex Telehealth Pittsboro Please indicate a primary concern/issue: * Adoption Trauma Anger Anxiety Attachment Issues Autism Behavioral Addiction, Compulsion (gambling, video games, etc.) Binge Eating Bipolar Body Image Borderline Personality Boundaries Cancer, Illness Caregiving Child Conduct, Acting Out Childhood Trauma Chronic Illness, Chronic Pain Codependency Communication Conflict Management Coping Skills Depression Dissociative Identity Disorder Divorce Domestic Violence, Abuse Disordered Eating Emotional Regulation Family Relationships First Responder Gender, Sexual Identity Grief Hoarding Impulse Control Issues Infidelity Issues of Fertility, Miscarriage Life Transitions Managing Mood Marital, Premarital Issues Men’s Issues Narcissistic Personality Disorder Neurodivergence (ASD, ADHD, dyslexia, etc.) Non Monogamy (open relationship, polyamory, swinging, etc.) Obsessive Compulsive Disorder (OCD) Paranoia Parenting Peer Relationships Personality Disorders Prenatal, Pregnancy, Postpartum (Maternal Mental Health) Psychosis PTSD Racial Identity Relationship to Food, Body Schizophrenia School Issues School or Work Stress Self Esteem, Self Confidence Self-Harm (cutting, etc.) Sex Positivity, Kink Sex Therapy Sexual Abuse Skin Picking, Hair Pulling Social Skills Spirituality Sports Performance Stress Substance Use Suicidal Ideation Tantrums Transgender Issues Trauma (acute incident) Veterans Weight Neutrality, Health at Every Size, Intuitive Eating Women's Issues Navigating Custody Issues Active Divorce Litigation Coparenting Support If applicable, please indicate a secondary concern/issue: Adoption Trauma Anger Anxiety Attachment Issues Autism Behavioral Addiction, Compulsion (gambling, video games, etc.) Binge Eating Bipolar Body Image Borderline Personality Boundaries Cancer, Illness Caregiving Child Conduct, Acting Out Childhood Trauma Chronic Illness, Chronic Pain Codependency Communication Conflict Management Coping Skills Depression Dissociative Identity Disorder Divorce Domestic Violence, Abuse Disordered Eating Emotional Regulation Family Relationships First Responder Gender, Sexual Identity Grief Hoarding Impulse Control Issues Infidelity Issues of Fertility, Miscarriage Life Transitions Managing Mood Marital, Premarital Issues Men’s Issues Narcissistic Personality Disorder Neurodivergence (ASD, ADHD, dyslexia, etc.) Non Monogamy (open relationship, polyamory, swinging, etc.) Obsessive Compulsive Disorder (OCD) Paranoia Parenting Peer Relationships Personality Disorders Prenatal, Pregnancy, Postpartum (Maternal Mental Health) Psychosis PTSD Racial Identity Relationship to Food, Body Schizophrenia School Issues School or Work Stress Self Esteem, Self Confidence Self-Harm (cutting, etc.) Sex Positivity, Kink Sex Therapy Sexual Abuse Skin Picking, Hair Pulling Social Skills Spirituality Sports Performance Stress Substance Use Suicidal Ideation Tantrums Transgender Issues Trauma (acute incident) Veterans Weight Neutrality, Health at Every Size, Intuitive Eating Women's Issues Navigating Custody Issues Active Divorce Litigation Coparenting Support Scheduling Preferences * Select all that apply. Morning Afternoon Evening Weekend [Limited Offerings] Additional scheduling preferences (preferred days, etc.): Is there anything else you’d like us to consider when determining the best-fit clinician to support you? Please note any provider preferences you may have, such as specialty (DBT, EMDR), clinician of color, faith-based, etc. 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. 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. Insurance Self-Pay Reduced rate with a Clinical Student Intern REQUIRED FOR INSURANCE USERS: Please upload the following to have your insurance verified.
