Carolina Center for Counseling

& Behavioral Interventions, LLC

Forms:

 

The first two forms (three for children) can be completed prior to your initial appointment.  It can be returned to us via email, fax, or mail.

New Client Information

This form provides the opportunity for you to share information about yourself or your child.  If we receive this information prior to your appointment we can obtain pre-authorization from your insurance company.

 

**You may be prompted to disable macros when viewing this document.  Select Disable to maintain full functionality of the document.**

 

PDF version of form—can be printed and filled out

Financial Information

This form can be used to register for any of the groups offered.  Click here for more information.

Referral Form

The Referral Form allows other professionals to let us know of referrals made to us.

Please do not hesitate to let us know if you have any questions.   We would be glad to email you a copy of the form if that would be more convenient.

This form provides basic background information for children and adolescents.

PDF version for printing

Child and Adolescent Background

Group Registration Form

This form describes our billing practices. 

We accept most major insurances. We do file the claims for you. We currently do not bill Medicaid or medicare. If your policy requires Pre-certification please obtain an authorization number prior to your first appointment.