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Patient Referral
Which Location are You Referring a Patient to?
Old Salem
Reynolda & Polo Road
Off Country Club Road
Clemmons
Greensboro
High Point
Boone
Cary
Patient's Name
(Required)
First
Last
Patient's Email
Patient's Phone
(Required)
Patient's Date of Birth
(Required)
MM slash DD slash YYYY
Patient's Gender
(Required)
Male
Female
Other
Other Gender
Type of treatment they are seeking
Therapy
Medication
TMS (Transcranial Magnetic Stimulation)
Esketamine (Spravato)
Postpartum Depression
Group Therapy
DBT Program
Other
Not Sure
Which office would they prefer?
Winston-Salem
Greensboro
Clemmons
Boone
High Point
Cary
Anything else you'd like us to know?
Insurance Information
This is optional. However, if you provide this information, we are able to authorize their plan and get them seen more quickly.
Insurance
Aetna
BCBS
CBHA
Cigna
Medcost
Medicare
Magellan
United/UHC
WFU/NCBH Employee
We are in network for most major insurers. However, we are not in network with Medicaid. We accept Aetna, BCBS, Cigna, CBHA, MedCost, Medicare, Magellan, and United Health Care.
Insurance ID#
Make sure to include the two numbers at the end (after the hyphen) if applicable.
Insurance Group#
Your Information
Name
(Required)
First
Last
Email
Phone Number
(Required)
Thank you!
We appreciate your referral and will reach out to them to schedule.
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(336) 722-7266