Initial Inquiry Form

Completing this form will alert our staff that you would like more information about therapy services for your child. Our Intake Coordinator will be in contact with you within three business days to gather more information, set up a time to speak with a therapist on the phone, and potentially schedule your child for services. Completing this form will help our Intake Coordinator and therapists prepare for their phone call with you.


If you would like assistance to complete this form, please contact us at (919) 928-0204.

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Emerge is an identify-affirming practice and a safe space. We ask for your child's pronouns so that we may address them in a way that feels comfortable for them and is identity-affirming.


  • If you would like to learn more about why we ask for pronouns, follow this link.
  • If you would like to read more about how using chosen names and pronouns can help reduce depression symptoms and suicidal ideation in teens, follow this link.
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Please include your area code.

This opt in is for company communication regarding scheduling and care, not an opt-in for marketing materials.

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Please provide the name of the person or place that recommended you seek services at Emerge.

Insurance Information

Emerge Pediatric Therapy is an in-network provider for all Tricare insurance plans, and NC Medicaid and Managed Care plans. We will bill these plans directly and collect any co-payments and deductibles as necessary.


We are out-of-network for private commercial insurance plans. Please visit our FAQ page on our website to learn more: https://www.emergepediatrictherapy.com/about-us/faq/

Please select all insurances that apply:

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