Counseling Intake Form

Counseling Intake Form
Completing our intake process can take 10-15 minutes, and once you begin, you cannot return to this page. Please have the following items ready before you start:
- A valid photo ID
- Your insurance card
- Any legal paperwork establishing custody or guardianship
After clicking Submit on the screening form, you will be redirected to our e-signing platform, SignNow, to review and sign our intake paperwork to become an established client.

If you would like assistance while completing the paperwork, our services coordinator is available to guide you over the phone. Call us at 910-493-3555 for support, or schedule a brief visit with our receptionist for a tour of the clinic.
Are you 18 years or older and legally able to make your own decisions, or are you a parent/legal guardian completing this form for a minor or someone under guardianship?*

Yes, I am 18 or older and can legally make my own decisions.No, I am completing this form as a parent/legal guardian for a minor or someone under guardianship.
Before we can schedule your appointment, you'll need to complete our intake paperwork. Once you finish this screening form, we'll send the documents to you. How would you prefer to receive your intake forms?*

Text Message (SMS)Email
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Language*

EnglishSpanishOther

Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Email (If different from client's email)
example@example.com
Do you have legal paperwork that establishes custody or guardianship of the child?(If so, you will be asked to upload it.)*

No — I am the legal caregiver, and no custody paperwork exists.Yes — I have legal custody/guardianship and will upload documentation

Please upload the legal paperwork establishing custody or guardianship (e.g., custody order, DSS paperwork, guardianship documents). *

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Will you be filing insurance?*

Yes, I will be using an insurance to pay for services.No, I will be paying out of pocket for services.
Do you have a secondary insurance?*

Yes, I am covered by two insurances.No, I am covered by one insurance or I will be self-pay.

Upload the front of the insurance card covering the client.*

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Upload the back of the insurance card covering the client.*

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Upload the front of the secondary insurance card covering the client.*

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Upload the back of the secondary insurance card covering the client.*

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Mental Health History
Why you are seeking treatment?*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNo
Are you willing to be seen via Telehealth?*

YesNoMaybe/Unsure
Are there any open DSS investigations/custody issues we need to be aware of?*

YesNo
Questions and/or Requested Provider

You are almost there!
After clicking Submit, you will be redirected to our e-signing platform, SignNow, where you can review and sign our clinic policies. This ensures that you are fully informed about important clinic information before getting started.

If you would like assistance while completing the paperwork, our services coordinator is available to guide you over the phone. Please call us at 910-493-3555 if you’d like support, or schedule a brief visit with our receptionist for a tour of the clinic.

Important: Once you click Submit, you will not be able to return to this page. Don’t hesitate to reach out if you need help completing the forms.
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Mental Health History