top of page

Home
Play Therapy
Contact US!
Services
Meet our Staff
More

Use tab to navigate through the menu items.

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*

Month

Day

Year

Gender*

Male

Female

Other

Address*

Email*

Phone (add a 1 then your 10 digit number, e.g., 1704-333-3333)*

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

AOTC Kings Mountain

Preferred Therapist

Cindy Berg, LCMHC

Kelly McCall, LCMHCA

Laura Stroupe, LCMHC

Shane Gomes, PhD

Elise Trompeter, PsyD

Liliana Chapman, LCSWA

Maria Smalls, LCMHCA

Alex Piro, Clinical Mental Health Intern

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, Placement Letter, or Affidavit for the client?

Yes

If yes, please upload the document 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
510 W King Street, Kings Mountain, NC 28086

bottom of page