Name *

First Name

Last Name

Phone

(###)

###

####

I am a

Parent/legal guardian

Prospective client

Professional

Are you or your child diagnosed with or suspected of any of the following? *

Social Anxiety

Selective Mutism (SM)

Separation Anxiety

Autism

Obsessive Compulsive Disorder (OCD)

Phobia

Other

Insurance/fees *

SM of the Carolinas accepts most BCBS plans until 1/1/2023 or is an out of network provider at a rate of $160/session.

I am aware of the out of network investment of $160/session. I am aware I can check if my insurance has out of network benefits.

I am interested in

Individual/Family treatment

Caregiver support group

Training for school, daycare, etc

Professional consultation

SPACE treatment

Sessions *

SM of the Carolinas requires approximately 6-8 weekly sessions of caregiver training. Are you able to commit to this?

Yes

Now may not be the time

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