Appointment Inquiry Form

Please complete the form accurately and in full to ensure a timely response.

If you select an insurance carrier but do not provide the subscriber or member number, we will Not contact you.

Terms & Conditions

First Name

Last Name

Date of Birth

Telephone

1st Choice Provider

Asya M. Little - minimum age 15 - Sunday - Tuesday; Self Pay Rate = $150.00 per session Kierra M. Mundine - minimum age 14 - Monday & Tuesday appts; Self Pay Rate = $150.00 Lawanna D. Brown - minimum age 30 - Waitlist; Self Pay Rate = $150.00 per session

2nd Choice Provider

Insurance Carrier - We Do Not Accept Medicaid or Medicare

No Insurance/Self-Pay Aetna Aetna State Health Plan (CPP provider) BCBS (if your subscriber number start with XHB, we do not accept Medicaid) Centivo Cigna/Evernorth Healthgram Humana (not Medicare) Optum/United Healthcare/UMR/UBH (if your subscriber number ends with a Letter, we do not accept Medicaid)

Subscriber ID/Member ID - if not using insurance, enter N/A.

Privacy/Terms & Conditions

“I agree with the Privacy Policy and Terms and Conditions”

Electronic Communication

“I agree to receive text messages from Progressing through Therapy. I understand that message frequency varies and data rates may apply. I understand that I may opt-out by replying "STOP" at any time. I understand that I may reply "HELP" for assistance. I understand consent is not required to purchase goods or services.”

Email:

execadmin@progressingthroughtherapy.com

Address:

418 S. Eugene Court Greensboro, NC 27401
(336) 365 – 8354

All Sessions are In-Person

Progressing through Therapy, PLLC