You’ve Got Questions…we’ve got answers! PLUS, we want to be sure Wellness is the right fit for you.

Important Information:

Our fees range from $100 – $410 depending on the service and therapist you select.
We are out-of-network and DO NOT accept insurance, however, we can provide you with a receipt to submit an insurance claim.
Wellness offers both In-Person and Online Sessions.

Your Name*
First Last
IMPORTANT (check below)*
I understand Wellness does not accept insurance and is considered an out-of-network provider. If I choose to submit an insurance claim, Wellness will provide a receipt that includes required information and billing codes.
IMPORTANT (check below)*
I understand Wellness offers both In-Person and Online Sessions.
IMPORTANT (check below)*
I understand fees range from $100 – $410 per session depending on the service and therapist I select.
Email*
Phone Number*
Age*
Spouse/Partner Name and Age*
How long have you been together?*
Do you have children?*
- Yes
- No
What are the ages of your children?
Briefly explain the issues and concerns you’d like to address:*
I am most interested in:
- Pre-Marital Counseling
- Week-to-Week Couples Therapy
- Family Therapy
- 1 Day Intensive
- 2 1/2 Day Intensive
- Individual Counseling
Have you ever been in therapy before?*
- Yes
- No
If yes, please share with whom plus a few details about your experience:
Occasionally, we will send updates, tips and ideas about relationships via our eNewsletter. You can unsubscribe at any time.
- Opt-out

309 S. Sharon Amity Road, Suite 310, Charlotte, NC 28211

Please understand that we do not accept insurance.