Contact | Project YES

Get in Touch

Please use the form below to get in touch if you require additional information (for non emergency contact only).

Contact Details

(919) 355-5633

If you would like information about our services, please complete the form below.

What does your inquiry relate to?(Required)

If you are interested in therapy services, we request that you send all of the following information that helps us with expediting the process of getting back to you and seeing how we can be of help.

Your full name as it is on medical records(Required)

Your preferred name if different from above

Date of Birth(Required)

Month

Day

Year

Full Name(Required)

Organization or your practice name (if applicable)

Are you in a training program?(Required)

Yes

At which academic institution or organization?(Required)

Email(Required)

Best Phone Number(Required)

Is it okay to leave a message at this number?(Required)

Yes

Is it okay to send a text to this number?(Required)

Yes

What are you seeking help with? Please describe in 1-2 sentences.(Required)

If you are intending to use insurance, what form of insurance do you have?(Required)

What state are you located in?(Required)

If anyone referred you, please indicate their name.

Phone(Required)

Topic or area you are interested in having training, presentation, or professional supervision in:(Required)

Date of engagement or training need:

Are you interested in private, public, or workshop classes? (Check all that apply.)(Required)

Private

Public

Workshops

Any information that would be helpful for me to know before we connect:

Please let me know what interests you in terms of our opportunities(Required)

How did you hear about Project Yes?

Please note: Information submitted through this form goes to a confidential inbox. However, it is not constantly monitored and is not appropriate for requesting emergency services. If you are having an emergency, please call 911 or 1800 273 TALK (8255) or go to the nearest emergency room.

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