CONTACT US TO SCHEDULE AN APPOINTMENT

If you're interested in learning more about our services or receiving personalized assistance, please complete the form below. We're eager to assist you! You can also reach out to us directly by calling or texting at 910-849-3399

As a client, you’ll have the freedom to select your preferred therapist.  However, certain factors may influence or limit your choices. Completing the brief questionnaire below will assist our team in providing tailored recommendations based on your needs and preferences.

Once you’ve submitted the questionnaire, our office staff will carefully review your information and reach out within 1-2 business days with counselor suggestions.

If a Inspiring Change PLLC staff member referred you, kindly contact our front office at the number provided above for expedited assistance.

PLEASE NOTE: This form does not schedule appointments. To proceed with scheduling your initial session, you’ll receive secure digital registration forms sent by our front office from Inspiring Change PLLC.

GENERAL INFORMATION

Client's Name
Client's Date of Birth
Phone Number
Email Address *
Is the client under the age of 18?

SPECIAL CONSIDERATIONS

Did someone specifically recommend Inspiring Change PLLC?
To ensure avoidance of any conflicts of interest, we have two additional questions:Is any of your family or close relations currently receiving care at Inspiring Change?
Has any of your family or close relations received care at Inspiring Change in the past?

INSURANCE/BILLING

Are you intending to utilize insurance for payment of your counseling services?

If yes, please provide the following.

Insurance Carrier
Insurance ID Number
Services Requested
Clinician preferences
What concerns are you looking to address in therapy?
Is there anything else you would like to share regarding your health concerns?
What days of the week are typically convenient for you to attend sessions?
What times during the day are typically suitable for your session availability?
Is there anything else you'd like us to know?