Free Phone Consultation

Please correct the errors described below.

This form is HIPAA compliant

First Name

Last Name

Preferred Pronouns

Phone Number

DOB

Email address

Have you ever been hospitalized for mental health reasons? - If yes please specify

Have you ever attempted suicide- If yes please specify

Which service are you interested in?

Initial Evaluation

ADHD Evaluation

Medication Management

Pharmacotherapy Consultation

Pharmacogenetic Testing

What's the reason behind this appointment?

Please select the best time for a call back and our clinical coordinator will reach out to you (Ok to select multiple time and days)

7am-10am

10am-12pm

12pm-02pm

02pm-05pm

05pm-07pm

Monday

Tuesday

Wednesday

Thursday

Friday

This phone consultation is completely free. However, note that we only accept Blue Cross Blue Shield, Aetna,Cigna,and UnitedHealthcare - for all other insurance plans or cash pay, clients may request an itemized bill to provide to their insurance company for reimbursement.

Please make your selection below

Please check our Insurance & payments page for more information

If possible, please submit a clear photo or scanned copy of your insurance card (both front and back)

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How did you hear about us?

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This form is HIPAA compliant

Chapel Hill Psychiatric Services

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