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Appointment Request Form

Please fill out the details in the form below to submit a new appointment request for Art of Therapy Center. DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

Referring Provider Details

Referring Provider Name (if Applicable)*

Reason for appointment*

Is the Client under 18 years of age?*

Urgency

Routine

Urgent

Client Information

First Name*

Middle Name*

Last name*

Birthday*

Gender*

Male

Female

Other

Address*

Email*

Phone*

Client Insurance

Insurance Company*

Policy ID Number*

Is the Client the Policy holder?

If no, who is? And what is their Date of Birth?*

Appointment Details

How did you hear about us?*

Friends/Family

Provider

Self

Internet

Other/Not Listed

Referring Provider

Reason for Referral*

Appointment Preferences

Preferred Location:*

Any Location/First Available

AOTC Gastonia - Audrey

AOTC Gastonia - Garrison

AOTC - Kings Mountain

Preferred Therapist

Cindy Berg, LCMHC

Kelly McCall, LCMHCA

Laura Stroupe, LCMHC

Shane Gomes, PhD

Elise Trompeter, PsyD

Tillie Mitchell, LCSW

Kristen Leach, LCMHC

Madison McClure, LMFT Intern

Alex Piro, Intern

First Available

Preferred Day of the Week *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Any Day/First Available

Preferred time of day

Morning

Afternoon

Evening (5, 6, 7 pm slots)

Is there a Custody Agreement? If yes, please upload it here

Please upload your insurance card?

Please upload any testing or other documentation you have from other mental health professionals related to this appointment.

Art of Therapy Center, PLLC

admin@artoftherapycenter.com

(980) 484-2111 {P}

(704) 259-0480 {F}

2925 Audrey Dr., Gastonia, NC 28054

1708 E Garrison Blvd., Gastonia, NC 28054
510 W King Street, Kings Mountain, NC 28086

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