Raising Resilience Referral Form

Raising Resilience provides virtual mental health support with a focus on maternal mental health and the emotional experiences of pregnancy, postpartum, parenting, fertility, and loss.

We prioritize supporting Black mothers, birthing individuals, and families, with the goal of increasing access to culturally responsive, compassionate care for communities that have historically been underserved.

We currently serve clients located in North Carolina and Washington, DC.

• North Carolina: insurance and self-pay options available

• Washington, DC: self-pay only

After you submit this form, a member of our team will reach out within 24–48 business hours to discuss next steps

Potential Client's First name

Potential Client's Last name

Potential Client's Date of Birth

Month

Day

Year

Potential Client's Email

Please use an email you check regularly for updates.

Potential Client's Phone Number

Who are you seeking services for?

If you are seeking services for someone else, please include your name and contact information.

Where is the potential client located?

I understand services are currently offered via virtual therapy.

What type of support are you seeking?

How do you plan to pay for services?

Accepted private insurance plans include:

Aetna, Cigna, United Healthcare, Blue Cross Blue Shield, and MedCost.

For North Carolina Medicaid, we currently accept the following managed care plans only:

UnitedHealthcare Community Plan, Healthy Blue, AmeriHealth Caritas, Carolina Complete Health, and WellCare.

What times of day generally work best for you?

In 1–2 sentences, briefly share what you’re hoping to get support with.

Raising Resilience specializes in maternal mental health. Do any of the following apply?

I understand that submitting this form does not guarantee placement in services.

I understand that if my needs fall outside Raising Resilience’s scope, I may be referred to another provider.

I confirm that the email provided is checked regularly for follow-up.