Intake Forms for New Clients
For an in- person appointment, please print and fill out the intake form that applies to you or your child. Please bring your completed forms and a copy of your insurance card with you to your appointment. If you are doing a telehealth appointment, please DO NOT print them if sending electronically, please fill them out on your computer/tablet and email them ([email protected]). You may also print and fax them to us at (828)586-5527 or mail them back to our office before your appointment.
-Thank You
-Thank You
Our intake forms are now password protected for confidentiality. You will need to call our office at 828-586-5555 to get the password. You may complete the forms on your computer or tablet, save them, and send them back to our office for your appointment. Please, if at all possible, fill the forms out in Word, if this is not an option for you (using Pages, etc on a Mac), please don't forget to convert/export the forms back to Word so that we may open them . If you have any issues, questions, or concerns please do not hesitate to call our office at 828-586-5555.
Adult Intake
These forms are for regular individual appointments with Melanie Vick.
This is for child counseling as well as child testing appointments with Bianca Aufiero. We need the child (11-17 ) to fill out the DSM-5 Self-Rated Measure, and the parents of children 6-17 to fill out the Parent/Guardian- Rated Measure.
Thuy Do, LCMHC
This is for child counseling appointments with Thuy Do. We need the child (11-17 ) to fill out the DSM-5 Self-Rated Measure, and the parents of children 6-17 to fill out the Parent/Guardian- Rated Measure.
These forms are for regular in person and telehealth counseling appointments with Thuy Do. For telehealth appointments, fill out the telehealth consent form as well as the intake packet prior to your appointment. Please send them to our office either by email or fax (above).
Runy Thao, LCSW
These forms are for regular counseling appointments with Runy Thao.
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Suzanne Stone, LCMHCS
These forms are for regular individual and children 16-17 year old counseling appointments with Suzanne Stone. For the ACE questionnaire, read each statement and circle either yes or no. For children appointments, we need the child (11-17 ) to fill out the DSM-5 Self-Rated Measure, and the parents of children 6-17 to fill out the Parent/Guardian- Rated Measure. For telehealth appointments, fill out the telehealth consent form as well as the intake packet prior to your appointment. Please send them to our office either by email or fax (above).
Lauren March, PsyD
These forms are for adult individual counseling appointments with Lauren March. For the ACE questionnaire, read each statement and circle either yes or no. For telehealth appointments, fill out the telehealth consent form as well as the intake packet prior to your appointment. Please send them to our office either by email or fax (above).
Bianca Aufiero, LCSW
These forms are for regular individual counseling appointments with Bianca Aufiero.
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Faith Cook, PsyD
These forms are for regular in person and telehealth counseling appointments with Faith Cook. For telehealth appointments, fill out the telehealth consent form as well as the intake packet prior to your appointment. Please send them to our office either by email or fax (above).
Anna Clark, LCHMC
This is for child counseling appointments with Anna Clark. We need the child (11-17 ) to fill out the DSM-5 Self-Rated Measure, and the parents of children 6-17 to fill out the Parent/Guardian- Rated Measure.
These forms are for regular in person and telehealth counseling appointments with Anna Clark. For telehealth appointments, fill out the telehealth consent form as well as the intake packet prior to your appointment. Please send them to our office either by email or fax (above).
Katie Dewhurst, LCMHC
These forms are for regular individual/ couples counseling Katie Dewhurst. If the appointment is for couples, both patients need to fill out one copy each of the paperwork.
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Good Faith Estimate Forms/Information
***FOR SELF-PAY CLIENTS ONLY***
As of January 1, 2022, if you are a new SELF-PAY client, please download this form as well and read over the information before your appointment. If you would like, you may bring a copy with you to your appointment, but if not, one will be provided for you at your appointment. If you have any questions or concerns after reviewing the information, please feel free to contact our office at (828)586-5555 and speak with our CEO, Chimene Mathis.
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