Self Referral form for Mental Health Services

The information provided on this referral form is confidential and secure

Client Information

Insurance Payment Information

Wrights Care Services is in network with Aetna, Blue Cross Blue Shield, Cigna, Magellan, Medcost, United Healthcare, and accepts Medicaid/NC Healthchoice (Sandhills). Our rates for services are $150 for the intake appointment and $120 for each following appointment.

Briefly describe the reason you are in need of mental health services.