Offering:

In-Home Child & Family Therapy
Professional Parenting Support
Infant Mental Health

Client Registration Form

Additional Information

If I have any other insurance/none of the above, I understand that services will be Fee For Service: ($145/$110)

Yes (*skip to doctor information)

Scheduling Needs?

City or Town

**Certified secure https site**

Phone

It is important that you complete the application fully by answering each question below. If you experience technical difficulties or problems, email your questions, comments or needs to Intake@carolinaparentingsolutions.com

Type of Child's Insurance Plan?

BCBS

NC Medicaid (NC Tracks/NC HealthChoice/Cardinal Innovations)

SC Medicaid (Healthy Connections/Tefra/Molina/ATC-Cenpatico)

None of the above

Any flexibility in your stated availability?

Filling out this form is important in order to assess that we are the appropriate provider, that outpatient child treatment is the appropriate level of care and to see if there is a Therapist in your area that can serve your location.

*Our Intake Coordinator will respond to your inquiry for new services generally with 3-5 business days.

*The initial response will come from our Intake Coordinator by email:

Intake@carolinaparentingsolutions.com

Are there other different providers working or have worked with your child &/or family?

Your child's Pediatrician Group?

Insurance Member ID#:

Zip Code

Group ID#:

Let's Get Started!

Child's Date of Birth

Parent(s) Name(s): *

Policy Holder's Name, Date of Birth, Workplace?

Child's Name

Home Address: Street # & Street Name

Our therapy services remain in high demand. We sincerely want to help all families we can reach. We will process your request as quickly as we can and let you know what options there are for services in your area. To be seen without delay, may require flexibility in your schedule. Afternoons and later evening appointments remain scarce at times. Sessions are generally weekly. Each session lasts about 45-50 minutes and occur over a period of time in order to most effectively affect long term, positive change and desired outcomes.

* Required Item.

Upload File

Parent(s) Email:

Does your child attend preschool/daycare/school-where?

Concerns/Challenges/Problems you are having?

Carolina Parenting Solutions, PLLC

Phone: 704-718-8657

Fax: 877-735-8447
ashley@carolinaparentingsolutions.com