Request First Visit

Request First Visit

Thank you for completing this registration form. The more information we have, the faster we can get you scheduled.
Today's Date


Patient's Name(Required)
Preferred Name
(If different from name listed above)
Date of Birth(Required)
Tell us more about your gender identity
Parent/Guardian 1
Parent/Guardian 2
This will allow you to schedule appointments on our patient portal.
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I'd like you to contact me about my first visit by
(Check as many as you would like)
Please send appointment reminders to my:
Patient's Address(Required)
Billing Address
Enter a billing address if different from the address above

Payment & Insurance

If you don't see your insurance below, we are probably out-of-network. If that's the case, select "Private Pay." We can still submit bills for out-of-network benefits, however, you would need to pay the full rate at the time of service.
Payment Method(Required)
Insurance Name(Required)
Mental health benefits can be tricky to navigate, but we will do some of that for you. All we need is the front and back of your insurance card. Most clients take a digital photo and upload it below. If that doesn't work, you can email your card to [email protected], fax to 336-201-0538, mail to MTC New Patients / 713 Marshall St SW, Winston-Salem, NC 27101, or text it to 336-722-7266.
Max. file size: 128 MB.
Max. file size: 128 MB.
Primary insured's name
(If not yourself)
Primary Insured's Date of Birth(Required)

Treatment Preferences

Which office(s) work best for you?(Required)
Do you need to use telemedicine during the coronavirus pandemic?
Do you need to be seen urgently (in the next 2 business days)?
Call or text us at (336) 722-7266 as soon as you have finished this form. We can usually get you seen within 2 business days.
Treatment you are seeking(Required)
All of our therapists work with anxiety, depression, bipolar, and relationships. A few of our therapists have additional training in specialized areas, please let us know if you are looking for that.
Specialized areas for therapy
Below are group therapies we offer throughout the year. We'll let you know when a group with you interests opens up.
Group Therapies
Many of our groups are available through teletherapy during the pandemic
I prefer to see a therapist who is a
Can we notify you sooner if appointments become open?(Required)