top of page

Request an appointment & Client Portal Login

Home
About
Services
Insurance
Referral Form
Resources
Blog
More

Use tab to navigate through the menu items.

Holding Hands

Referral Form

Want to make a referral?

Referral Source (Agency/Provider Name)

Agency/Provider Phone Number

Agency/Provider Email

Client's First and Last Name

Client's Date of Birth

Client's Telephone Number

Client's Email Address

Reason for Referral

Release of Information Form

Upload File

*Please Attach* Upload up to 5 supported files. Max 10 MB per file.

Thank you for the referral!

Find your peace

Let's Connect

Ready to start your journey to peace?

Reach out to schedule a consultation.

We look forward to meeting you and learning how we can support you.

📧contact: moorepeacecounselingwellness@gmail.com

📱(984)302-6412

📍Telehealth Services Available

Contact Us

Fill in the form below to let us know which service you're interested in

and how we can help - we'll get back to you as soon as possible.

First name*

Last name*

Phone number*

Which service are you interested in?

Add a message or tell us more about what you need

Serving North Carolina

Accessibility Statement

© 2026 by Moore Peace Counseling & Wellness PLLC

Request an appointment

bottom of page