New Client Forms

For your convenience, our intake forms are available to print from the website.  Choose the intake packet that is listed for your counselor and that is for the appropriate age bracket.  For example, if you are seeing Jennifer and if the client is a child, print all forms from that section.  Carefully read and complete the intake forms IN BLACK INK and bring them with you to your first appointment.  Please bring all pages of the forms (not just the signature pages); we will be happy to give you copies of them if you wish.  This will save a lot of time so we can make the best use of your first appointment!

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Office2
Chair

*For couples counseling, each partner needs to complete his or her own intake packet.

(Click on the intake packet that is listed for your counselor and that is for the appropriate age bracket. )

Jennifer's Intake Packet for Adults (Age 18 and older)
Jennifer's Intake Packet for Children (Ages 6 through 17)
Jennifer's Intake Packet for Couples* Counseling
Sarah's Intake Packet for Adults and Couples* (Age 18 and older)
Sarah's Intake Packet for Teens (Ages 15 through 17)
Emily’s Intake Packet for Adults (Age 18 and older)
Emily’s Intake Packet for Children (Ages 8 through 17)
J'Nae's Intake Packet for Children and Adolescents (Ages 3 through 17)
Robyn's Intake Packet for Adults and Couples*  (Age 18 and older)
Robyn's Intake Packet for Children and Adolescents (Ages 6 through 17)
Antoine's Intake Packet for Adults  (Age 18 and older)
Rebecca's Intake Packet for Adults and Couples* (Age 18 and older)
Rebecca's Intake Packet for Children and Adolescents (Ages 5 through 17)

Mary Margaret's Intake Packet for Adults  (Age 18 and older)
Patient Health Questionnaire 
Professional Disclosure Statement 
Authorization to Release Information
Notice of Privacy Practices 
Credit Card Payment Form
PHI Consent  
Acknowledgement of Financial Responsibility 

Mary Margaret's Intake Packet for Children and Adolescents (Ages 12 through 17)

Patient Health Questionnaire
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

Debbie's Intake Packet for Adults and Couples (Age 18 and older)
Debbie's Intake Packet for Children and Adolescents (Under 18)
Allen's Intake Packet for Adults (Age 18 and older)
Yoga Workshop Intake Packet
Parent Counseling Group Intake Packet (One Per family)
Sharing the Journey Group Intake Packet (One Per family)
Adolescent DBT Skills Group

LOCATION

6614 Shallowford Road, Suite 250 ~ Lewisville, NC 27023 ~ 336-945-0137

CONTACT US

Request an appointment or more information