New Patient Inquiry Form

PROSPECTIVE NEW PATIENTS:

We truly appreciate your interest in our practice!

​WE ARE CURRENTLY ACCEPTING

​NEW PATIENTS

FOR MEDICATION MANAGEMENT and for THERAPY! ​

​Please see our Staff page for more information on the availability of a specific provider.

If you are inquiring about appointments with our psychiatrist, Dr. Casey, she is not currently accepting new patients. We have other medication providers who practice under the close supervision of Dr. Casey, and all our providers work collaboratively as a treatment team. You can check out our providers’ bios here to see if one of them would be a good fit for you!

Please see our FAQs for questions about insurance, costs, assessments and evaluations.

Please provide us with the following information, so we can determine if we are a good fit for your needs. We will email or call you back within 5 business days. If you wish to schedule an appointment we will provide you with the required intake forms. The intake forms may also be downloaded here.  Once we receive your completed paperwork and a copy of your insurance card and ID, we will work to schedule your initial appointment as soon as possible.

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Completing the form below is the FASTEST way to get started with our services.​

* Indicates required field

Potential New Patient Name *

Preferred Nickname and/or Preferred Pronouns

Patient's Date of Birth *

Name of Person Completing This Form

Relationship to the Patient

Cell Phone Number *

Other Phone Number

Email *

Address (including zip code) *

Please note, response times will be faster via email and/or text messaging:

Is it okay for us to contact you via email? *

Yes No

Is it okay for us to contact you via text messaging? *

Yes No

Insurance:

We are in-network with most Aetna (except CVS Health HMO Bronze, Silver and Gold), BCBS (except BlueLocal, HealthyBlue, High Performance Network, and BlueHome with Novant Health), Cigna, and United Healthcare plans. Please contact your insurance to ensure your "Mental Health or Behavioral Health Benefits" are covered under one of these plans, as these benefits may be subcontracted to a different carrier than your main insurance coverage. Please also be aware that some plans purchased on the Marketplace are also out of network, even though they are through one of our In-Network companies.

**Please check with your insurance company to be sure that behavioral health coverage is included with your major medical plan, and that it's not covered by another insurance provider. This practice has opted-out of the Medicare Program. If you have Medicare, please be aware that Medicare will not pay for any service provided by this practice.**

What plan do you have FOR BEHAVIORAL HEALTH COVERAGE? *

Do you have Medicare or Medicaid in any form? *

Medicare Medicaid Both Neither

If our practice is not in-network with your insurance, do you want to continue pursuing services as a self-pay client? *

Please share your reason for wanting to make this initial visit: *

Are you interested in only therapy, only medication management, or both services? *

Medication management only Therapy services only Both medication management and Therapy services

Have you ever been hospitalized for psychiatric reasons? If so, when was the most recent and for what reason? *

Do you have a current psychiatrist and/or therapist? If yes, please give their names and as much contact information as you are able. *

What medications are you currently taking? Have there been any recent changes with these? *

Would you prefer the Chapel Hill or Raleigh location for appointments? (We are offering telehealth and some in-person options for therapy, however we do have limited providers and availability for in person therapy): *

Chapel Hill - 117 Hidden Valley Dr, Chapel Hill NC 27516 North Raleigh - 920 Paverstone Dr, Suite D, Raleigh NC 27615 Either Location Telemedicine Only

Initial Intake Appointments can be via video format or in-person, however you must be physically located in North Carolina to utilize our telemedicine services.

If you are requesting therapy, or therapy in addition to medication management, please list any preferences you have/things you are looking for in a therapist assignment: *

When are the best days/times for your appointment? *

How did you hear about our practice? If you were referred to us, who referred you? *

Is there a person, provider or practice that you would like to allow us to communicate freely with regarding your protected health information? This includes scheduling appointments on your behalf and gathering medical records from your other caregivers or providers. (Detailed information is not needed at this time.): *

Yes No

Submit Now

North Raleigh Mental Health and Wellness

920 Paverstone Dr, Suite D Raleigh, NC 27615

Chatham North Psychiatry

117 Hidden Valley Dr Chapel Hill, NC 27516

Contact Us Today:

Phone/Fax: 844-345-2256