New Patient Forms
Please download the form below that pertain to you. You may type directly in the form and print the completed form or print the form and print legibly to complete the form. Please bring the completed forms with you to your initial appointment.
Adult Intake Questionnaire (For ages 18 and over)
Couples Intake Questionnaire (This form must be completed twice, once by each person. Please bring both completed copies to your initial appointment.)
Aspiring Hearts Counseling is currently accepting referrals. Individuals can be any age and should reside within Wake County.
Referral Form (PDF Version)
Referral Form (MS Word Version)
Complete all of the required information in the form and submit the form by emailing it to firstname.lastname@example.org or faxing it to 1-888-325-6160 .
This form is required for Medicaid and Health Choice clients to start services. If you are a Physician’s office, please submit this form with the Referral Form above for Medicaid or Health Choice clients.