CONTACT ME

Request a free 15-minute phone or video consultation*

My office

3326 Durham-Chapel Hill Blvd

Suite A230

Durham, NC 27707

Contact

Whitney Winslow, LCSW

whitney@simplyflourishnc.com

‪(919) 205-8572‬

*My caseload is currently full. You are still welcome to reach out if you are interested in being added to my waitlist.

I do not have an estimate of when I will have availability for new clients.

CONTACT ME

Full Name of person who would receive services*

Date of Birth*

Phone Number of person who would receive services (or legal guardian if seeking services for an individual under 18 years of age)*

Email address of person who would receive services (or legal guardian if seeking services for an individual under 18 years of age)

Person completing this form (in relation to the person who would receive services)*

It's Me

Parent/Legal Guardian

Foster parent or kinship caregiver

Friend/Family Member (not legal guardian)

Person working with the individual as part of my job (teacher, school counselor, therapist, social worker, primary care physician, etc.)

Other (please describe below)

If you are completing this form to refer someone, please write your name and relationship to the individual

Phone number of person making the referral*

Email address of person referring

How did you hear about me?

Describe current challenges and the hope from therapy at this time*

Anticipated Form of Payment*

Aetna insurance

Out of Pocket/Self-Pay (will be provided with a Superbill for OON reimbursement)

I'm referring someone and I don't know the answer to this

Blue Cross Blue Shield of NC

Medicaid

Insurance Information (If you would like me to verify your insurance)

The best way to follow up to schedule the consultation*

Text Message

Email

In the event of a mental health emergency, please call 911 or go to the nearest emergency room. I do not provide emergency services, and cannot guarantee immediate availability in the event of an emergency.

My Office

3326 Durham-Chapel Hill Blvd

Suite A230

Durham, NC 27707

Contact

whitney@simplyflourishnc.com

‪(919) 205-8572‬

Whitney Winslow, LCSW

Request a free 15-minute phone or video consultation*

My office

Contact

*My caseload is currently full. You are still welcome to reach out if you are interested in being added to my waitlist.

In the event of a mental health emergency, please call 911 or go to the nearest emergency room. I do not provide emergency services, and cannot guarantee immediate availability in the event of an emergency.

My Office

Contact

Simply Flourish Psychotherapy Services, PLLC