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DEIB at Three Oaks
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DEIB at Three Oaks
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Apex
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East Raleigh
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Knightdale
Midtown
North Durham
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Pittsboro
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Clinical Student Interns
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Name of Client (Minor)
*
First
Last
Pronouns (Client/Minor)
Age/Date of Birth of Client (Minor)
*
Name of Parent/Guardian
*
First
Last
Pronouns (Parent/Guardian)
Parent's/Guardian's Email
*
Parent's/Guardian's Phone Number
Additional Contact Information (Email/Phone Number)
If there is an additional parent/guardian/family member you would like us to communicate with, please share their contact info above.
Preferred Contact Method
*
Select
Phone Call
Text Message
Email
How would you like us to get in touch with you?
Location Preference:
Downtown Raleigh
East Raleigh
North Raleigh
West Raleigh
Midtown
North Durham
South Durham
Pittsboro
Garner
Knightdale
Southern Village
Chapel Hill
Apex
Please note: we currently only offer assessments at our Apex office, but are looking to expand in the future. Your feedback is appreciated 🙂
How did you hear about Three Oaks?
*
Google
Word of Mouth
Psychology Today
Instagram
Current Employee
Current Client
School/University
Facebook
Flyer/Business Card
Other
Who referred you for Psychological Testing?
*
Select
Self
Parent/Guardian
Teacher/Professor
Another Therapist
Pediatrician/Doctor
Psychiatrist
Other
Insurance
*
Select
Blue Cross Blue Shield
Evernorth (Cigna)
Aetna
EAP
Other/Out-of-Network
Self pay (I will not be using insurance.)
We do NOT currently accept Blue Home, Blue Value, United, Medicaid or Medicare. We are in-network with BCBS (PPO plans), Evernorth (formerly Cigna), & Aetna. We also accept the NC State Health Plan and EAPs. Additionally, we are able to bill out-of-network with other major insurance companies. Please visit our FAQ page to learn more about billing & insurance.
What year in school is the client?
*
Select
Early Childhood (Preschool/Kindergarten)
Elementary School (Grades 1-5)
Middle School (Grades 6-8)
High School (Grades 9-12)
College (Undergraduate/Graduate)
Please note that we currently only assess individuals up to age 25.
What school/university does the client attend?
Has the client participated in an evaluation before?
Select
Yes
No
Unsure
What are the client's current areas of concern? Please select all that apply.
*
Academic skills and learning
Behavioral (e.g., attention, hyperactivity, impulsivity, executive functioning, aggression, etc.)
Cognitive abilities
Emotional (e.g., anxiety, depression, emotion regulation, withdrawal, self-esteem, etc.)
Early development and delays
Language and communication
Social skills and peer relationships
Adaptive skills (e.g., self-care, daily routines, navigating school/community, etc.)
Other concerns (Please describe in Message box below.)
Are you (the parent/guardian) interesed in learning more? Please check all that apply.
Parenting strategies
Psychotherapy services
Community resources and related service providers (i.e., occupational therapy, speech-language therapy, physical therapy, tutoring, etc.)
School-based supports (e.g., special education/IEP, Section 504 plan, intervention, specialized programs, etc.)
Unsure/I am interested in learning more. (Please describe in Message box below.)
Message
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