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Sylva Clinical - PSYCHOLOGY!
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    • Chimene Mathis, BS, CEO/PRESIDENT
    • Brittany Buttery, BS
    • Todd Morton, PhD
    • Faith Cook, PsyD
    • Lauren March, PsyD
    • Suzanne Stone, MA, LCMHC-S
    • Katie Dewhurst, MA, LCMHC
    • Thuy Do, LCMHC
    • Anna Clark, LCMHC
    • Bianca Aufiero, LCSW
    • Runy Thao, LCSW
    • Melanie Vick, LCSW, LCAS
    • Jerry Coffey, PhD
    • Laura Coffey, PhD
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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
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 

Adult Intake Packet
File Size: 212 kb
File Type: doc
Download File

These forms are for regular individual appointments with  Melanie Vick.  

Child Intake (Under 18)

Child Intake Packet
File Size: 296 kb
File Type: doc
Download File

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 
Thuy Child Intake Packet
File Size: 308 kb
File Type: doc
Download File

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. 
Thuy Adult Intake Packet
File Size: 223 kb
File Type: doc
Download File

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

Runy Adult Intake Packet
File Size: 217 kb
File Type: doc
Download File

These forms are for regular counseling appointments with  Runy Thao.   

Suzanne Stone, LCMHCS 

Suzanne Adult Intake Packet
File Size: 236 kb
File Type: doc
Download File

Suzanne Child Intake
File Size: 350 kb
File Type: doc
Download File

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 
Lauren Adult Intake Packet
File Size: 215 kb
File Type: doc
Download File

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 

Bianca Adult Intake Packet
File Size: 243 kb
File Type: doc
Download File

These forms are for regular individual counseling appointments with  Bianca Aufiero.    
Faith Cook, PsyD  
Faith Intake Packet
File Size: 1991 kb
File Type: doc
Download File

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
Anna Child Intake Packet
File Size: 307 kb
File Type: doc
Download File

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. ​
Anna Adult Intake Packet
File Size: 223 kb
File Type: doc
Download File

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

Katie Intake Packet
File Size: 227 kb
File Type: doc
Download File

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.

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. 
Good Faith Estimate Info & Form
File Size: 96 kb
File Type: pdf
Download File

It is the mission of Sylva Clinical - PSYCHOLOGY! to provide the highest quality psychological care in a compassionate environment to enhance the health and well being of the people we serve and our community.

Sylva Clinical - PSYCHOLOGY!
70 Westcare Drive, Suite 402
Sylva NC 28779
828-586-5555