College of Arts and Sciences
The Department of Psychology Community Clinic
Child and Family Clinic
Body Image Clinic
Use the link above to request a screening or ask a question
Clinic Site Navigation
Directions and Parking
Faculty and Staff
This form should be completed by (or with) a potential client.
Potential client NAME
First then last - i.e. Jane Doe:
Potential client EMAIL
Our preference is to get some initial contact information by email (all information provided is private and confidential) - may we do this? If so, please provide your email address - providing your email address means this will be our initial way to contact you to start the process (it is not used for any other purpose than for us to contact you regarding the information below):
If you only want to ask a question you may now skip to the last section...
Potential client PHONE
Even if you have indicated that we may contact you by email, please provide your phone number in case we need to speak with you directly:
If we don't reach you directly, is it ok to leave a message at this number?
Reasons for Contacting Us
What is your primary interest in our clinic?
Adult Couples Clinic
Adult Anxiety Clinic
You may provide additional information or ask a question here - please keep in mind you will be contacted and be able to speak with us directly:
Department of Psychology Community Clinic
| University of North Carolina at Chapel Hill | Davie Hall - Attn: Clinic | Chapel Hill NC 27599-3270
Phone: (919) 962-6906 | CONFIDENTIAL Fax: (888) 707-2987 |
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