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Home
Home
Appointment
Appointment
Services
Services
Cost
Cost
Contact
Contact
Counselors and Team
Counselors and Team
News
News
WELLness Blog
Scholarship
Scholarship
Donations
Donations
Resources
Resources
Give
Now
Appointment
Contact Us
To schedule an appointment, please complete the form below and we will respond within 1-2 days.
Name
*
First
Last
Email
*
Phone
*
Preferred method of contact to set appointment:
*
Email
Phone
Do we have your permission to contact you using the method of contact indicated above?
*
Yes
No
If phone, do we have your permission to indicate that we are calling from CCERC?
Yes
No
If phone, do we have your permission to leave a message?
Yes
No
Were you referred by the Social and Economic Vitality Program?
Yes
No
Were you referred by the NC State University Counseling Center?
Yes
No
Do you have health insurance that pays for counseling services? (Insurance is not required for our services).
Yes
No
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