Therapeutic Solutions of North Carolina

The Office Of Wayne Faison

Licensed Counselor, LCMHC, LCAS-A

For Emergencies Dial 911. Office 919-271-4710

Please complete the one page form below
Use the gray "add file" icon to upload your insurance information
Do NOT click the email "reply" button
Click the blue "Submit Your Confidential Info" button at the bottom of the page

Person Seeking Counseling

First name

Last name

Date Of Birth

Phone number

Is the person seeking counseling a child or teenager (under 18)?

Yes No

Person Submitting The Referral

Are you the person seeking counseling?

Yes No

First name

Last name

Relationship To Person Seeking Counseling

Parent/Guardian Spouse Other

Other

Street Address (include apartment number)

City

State

Zip Code

May we contact you by phone?

Yes No

May we leave you a voicemail?

Yes No

May we contact you by email?

Yes No

Email address

Reason for Seeking Counseling

What is the reason for seeking counseling? Include any info that might be helpful to the counselor.

Person Seeking Counseling - Medical History

Has the person seeking counseling been treated for mental health issues or a developmental disability?

Yes No

Has the person seeking counseling been hospitalized for mental health treatment?

Yes No

If yes, when, where, why?

Person To Contact In Case Of Emergency

Add another emergency contact

Employee Assistance Program (EAP) Information - Not Required

Do you have an Employee Assistance Program (EAP) you wish to use for telehealth?

Yes No

Your Employer

EAP Provider

EAP Authorization Number

Insurance Information

Insurance Card

Insurance cardholder - First Name

Insurance cardholder - Last Name

Insurance cardholder - Date Of Birth

Insurance cardholder's relationship to person seeking counseling

Self Spouse Parent/Guardian Other

Insurance provider

Insurance cardholder member number

Insurance cardholder group number

Upload Photo Of Front and Back Of Insurance Card

Take a photo of the front and of the back of your card, click upload for each

Add file

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Wayne Faison is a licensed clinical mental health counselor (LCMHC), a licensed clinical addiction specialist (LCAS-A) and a Christian counselor with over 15 years of mental health experience. He has two masters degrees: Christian Counseling from Apex of Theology and Professional Counseling from Grand Canyon University.

waynef@tsofnc.com
100 Parkway Court, Suite 100, Cary, NC, 27518