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.

pdf_icon-1 Adult Intake Questionnaire (For ages 18 and over)

pdf_icon-1 Child and Adolescent Intake Questionnaire

pdf_icon-1 Couples Intake Questionnaire (This form must be completed twice, once by each person. Please bring both completed copies to your initial appointment.)


Referral Form

Aspiring Hearts Counseling is currently accepting referrals. Individuals can be any age and should reside within Wake County.

pdf_icon-1 Referral Form (PDF Version)

word_icon Referral Form (MS Word Version)

Complete all of the required information in the form and submit the form by emailing it to or faxing it to 1-888-325-6160 .


Physician Referral

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.

pdf_icon-1 Physician Referral to Behavioral Health Services