Make a Referral to Myers-Galloway Counseling in Charlotte, NC

Empowering Black Women through Therapy

Myers-Galloway Counseling is a private, fee-for-service mental health practice offering one-to-one therapy for Black women who struggle with the negative mental health impacts of parentification. We support clients with anxiety, depression, grief, and trauma related concerns. Your client/patient will be assigned the earliest available clinician with expertise in the problem area, unless a preference is expressed below.

Submitting information using the form below is secure. Myers-Galloway Counseling has an active HIPAA Business Associate Amendment with Google Workspace/Cloud Identity.

Date of Referral

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Referring Professional's Contact Information

Please type your name, phone, email, the organization you represent, and address below in the event we need to contact you.

Is the client aware that you are making this referral?

Yes

Client Name

First Name

Last Name

Client Phone Number

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Client Gender

Male

Female

Non Binary

Client Email

Reason for Refferal

Please place any pertinent information here about the case.

Is the client a resident of North Carolina?

Myers-Galloway Counseling can only see patients who reside in the state of North Carolina.

Which service could your client benefit the most from?

Do you believe your client is able to commit to attending therapy on a weekly basis until their goals are met?

Yes

I'm not sure

How did you hear about Myers-Galloway Counseling?

Is the client looking to use insurance to cover the cost of therapy?

Currently Myers-Galloway Counseling accepts Aetna, BCBS, and United Healthcare. Please confirm with the client which insurance they have.

By submitting this form, you are consenting to receive marketing emails from: Myers-Galloway Counseling, 421 South Sharon Amity Rd., Suite C, Charlotte, NC, 28211, US, https://www.myersgallowaycounseling.com. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

Make a Referral to Myers-Galloway Counseling in Charlotte, NC

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