Forms

All forms may be filled out in advance and brought to the office on the day of your appointment, however, please note that all forms requiring a witness signature must be signed by the patient/legal guardian and witnessed by a member of the CCNC staff at our office.

Telehealth Consent Form Consent form must be completed and returned to our office prior to your telehealth appointment. We must be able to verify patient has completed the form themselves (or legal guardian).

New Patient Forms (14 pages) **For patients who are minors the legal guardian must be present at the initial appointment.  Please bring a picture ID, current insurance card, and co-payment.  If you are the non-biological legal guardian/parent, please bring (non-expired) legal paperwork assigning you as legal guardian.

NC HealthConnex Opt Out Form (3 pages)

Updated Paperwork (5 pages)

Account Change Forms (1 page – change of insurance, address or phone)

CCNC Patient Orientation Package (25 pages)

HIPAA Disclosure – Medical Records (If signed out of office, must be notarized)

HIPAA Disclosure – Medical Records Part 2 Release Substance Abuse Disorder (If signed out of office, must be notarized)

HIPAA Disclosure – Psychotherapy Notes (If signed out of office, must be notarized)