We’re excited to help you connect with a therapist that best fits your needs.

To get connected with a therapist, please fill out the information below. Upon submission, an intake coordinator will follow up with you within 24 business hours.

If you are filling out this form for someone other than yourself, please include the prospective client’s information.

Name

First Name

Last Name

If prospective client is a minor, name of parent/guardian

First Name

Last Name

I confirm that the person filling out this form is at least 18 years of age.

Date of birth

YYYY

City, state, zip code

Phone

(###)

###

####

Insurance

If unsure, please select "self-pay/out of pocket."

Which counseling services are you interested in?

If applicable, please specify which clinician you are interested in meeting with.

Please note that clinicians have limited availability and may not be accepting new clients. In the event that your preferred clinician is not available, our team will help match you with another therapist who fits your needs.

How do you find out about Carolinas Counseling Group?

If applicable, please specify who referred you to Carolinas Counseling Group.

What is the best way for our team to get in touch with you?

We use standard security practices to protect your information, but please be aware that no online communication can be guaranteed 100% private.