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Please do not include medical details or symptoms. We will discuss everything privately at your visit. If you are in crisis, call or text 988, or call 911.

About you

Street address

Your visit

Which service do you need?Primary careBehavioral healthOpioid use disorder treatment (MAT)Lab servicesNot sure yet
Visit preferenceIn person (Fayetteville clinic)Telehealth (must be in North Carolina during the visit)No preference
Are you seeking a new diagnosis or care for an existing diagnosis?No details needed. We will talk about this at your visit.A new diagnosisCare for an existing diagnosisNot sure
Were you referred by a provider or organization?YesNo
If yes, who referred you? (optional)

Contact preferences

Is it okay for us to call you?YesNo, please email me instead
If we miss you, may we leave a voicemail that mentions our clinic?YesNo, just ask me to call back
Best times to reach youMorningAfternoonEvening
How did you hear about us? (optional) —Please choose an option—Google searchReferred by a providerFriend or familySocial mediaCommunity organizationOther

Acknowledgments

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