Appointment

Name*

First Last

Email*

Phone*

Preferred method of contact to set appointment:*

Do we have your permission to contact you using the method of contact indicated above?*

If phone, do we have your permission to indicate that we are calling from CCERC?

If phone, do we have your permission to leave a message?

Were you referred by the Social and Economic Vitality Program?

Were you referred by the NC State University Counseling Center?

Do you have health insurance that pays for counseling services? (Insurance is not required for our services).

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