If you would like to request an appointment, please complete the form on this page to provide a few details. This will help me determine the best fit for you and your family as well as allow me to provide more information about our availability.

Please allow up to 48 business hours (not including holidays or weekends) for me to get in touch with you. I will contact you via email provided on this form.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Your Chid's Age

Areas of Concern

Note: Please briefly describe why you are seeking counseling services for your child. Please do not include Personal Health Information in this form.

Court Involvement

Do you have any active/past court involvement with a note saying "Our office requires all legal guardians to provide written consent for treatment?"

Yes

No

Insurance/Self-Pay

Are you hoping to use insurance benefits?

Scheduling Sessions

Accessibility Notice

Please note: Our counseling practice is located on the second floor. Please be aware that our building currently does not have elevator access. If mobility is a concern, please indicate and we will contact you to determine how we can best accommodate your needs.

Your Availability

If you have not selected "I am flexible," please provide a brief description of your availability for appointments. PLEASE NOTE: WE CANNOT GUARANTEE AN AFTER SCHOOL TIME SLOT FOR EVERY CLIENT.

Checkbox

I have read and understand that Hannah is currently not available to accept new clients at this time.

Contact Info

hannah@carolinacounselingandplaytherapy.com

150 Wind Chime Court, Unit B
Raleigh, NC, 27615

Hours
Monday–Thursday

By Appointment Only

Phone
(910) 319-9759