Counseling referral form

Please complete the following form to the best of your ability. Someone from our staff will contact you in response within two business days.

Counseling Services

* Indicates required field

Your Name *

First

Last

Your Email *

Contact Phone Number *

Desired Location for Treatment *

Mooresville Location Concord Location Statesville Location Charlotte Location

Name of Person for Whom Services are Requested *

First

Last

Age *

Primary Insurance *

Guardian's Name *

First

Last

Guardian Contact information *

Why are you seeking services *

Submit