Offering:

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

Carolina Parenting Solutions, PLLC

Phone: 704-718-8657

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

Client Registration Form

Additional Information

If I have any other insurance/none of the above, I understand that services will be Fee For Service: ($200/150)

Yes (*skip to doctor information)

Scheduling Needs?

City or Town

Phone

Type of Child's Insurance Plan?

BCBS

NC Medicaid (NC Tracks/NC HealthChoice/Alliance/Partners/Vaya/Healthy Blue/Wellcare/Carolina Complete Health)

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

We are currently NOT accepting new patients at this time for in-person therapy. For virtual parenting support options, please see Triple P Program Options above.

Parent(s) Name(s): *

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

Child's Name

Home Address: Street # & Street Name

Upload File

Parent(s) Email:

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

Concerns/Challenges/Problems you are having?