Getting Started

Carolina Parenting SolutionsPLLC

Families Interested in our services, please complete the

On Line Intake Registration Form

below

Insurance Member ID#:

Zip Code

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.

Parent(s) Email: *

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

Concerns/Challenges/Problems you are having? *

*Referrals

from Pediatricians & other professional providers accepted.

Please complete the

On Line Registration Form

below

on behalf of the patient you wish to refer to our services.

Yes! I want to apply for services, so "Let's Get Started" by completing the secure Online Registration Form below and submitting it.

We'll be working in the background to evaluate your needs, make sure we are the right services for you and see what availability we have to offer your child and family to get started with services.

Carolina Parenting Solutions, PLLC
Main Offices#: 704-718-8657
Fax#: 877-735-8447
carrie@carolinaparentingsolutions.com
Serving the areas of Greater Charlotte, North Carolina, surrounding counties as well as greater Fort Mill/Rock Hill, South Carolina, and all parts in between.

Having difficulty getting your form to submit?? **ALL "*" questions must be answered in order for your form to submit.

Go back and check that all questions are answered and try again.

**Certified secure https site**

Phone *

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

Your child's Pediatrician Group?

Let's Get Started!......

Child's Date of Birth *

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

Child's Name *

Home Address: Street # & Street Name *

Our Service Area includes :
Greater Charlotte, NC,

Huntersville/Mooresville/Cornelius, NC
Cabarrus County, NC
Union County, NC
Fort Mill, SC and Rock Hill, SC
(*depending on therapist availability, client location and your availability to be seen in your home with your child.)

Parent(s) Name(s): *

Online Intake 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 *

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?

Group ID#:

* Meetings By Appointment Only *

Apply for Services Now

with the

Online Intake Registration Form below