Name * First Name Last Name Email * Phone * (###) ### #### Insurance Type * Self-Pay Sliding Scale BCBS-NC Aetna United Healthcare Cigna Oscar Health Oxford Who request is for * Myself My Child Agency Referral Other Referring Agency if Applicable Service Type: * Individual Therapy Individual Therapy of Adolescent (13-17) Individual Therapy of Child (6-12) Couples Therapy Family Therapy Group Therapy Location Preference: * In Person (Sylva, NC) Telehealth Contact Preference Phone Call (AM) Phone Call (PM) Text Email Message * Thank you, you’re request has been sent. Emailmelissa@mountaindandelion.comPhone+1 (828)-341-6269 Request Appointment
