Offering:

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

Type of Child's Insurance Plan?

BCBS

NC Medicaid (we do NOT accept Amerihealth Caritas or United Healthcare Community Plan)

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

None of the above

Any flexibility in your stated availability?

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

Yes (*skip to doctor information)

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

Already a client with us and need Access to your Client Portal through Simple Practice? Click Here

or go to https://ashleyschlieper.clientsecure.me

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

Insurance Member ID#:

Concerns/Challenges/Problems you are having?

Additional Information

Scheduling Needs?

Phone

Parent(s) Name(s): *

*Please Note: Due to the overwhelming amount of families reaching out, we are completely booked at this time. If you would like to be placed on our waitlist, you can continue to fill out this form. If you are unable to wait, please return to your pediatrician or insurance provider for a list of other behavioral health agencies that may have more availability! We are working hard to hire more high quality Therapists to fill the need. Thank you for your understanding!

Zip Code *

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

Upload File

Let's Get Started!

City or Town *

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.

Your child's Pediatrician Group?

Client Registration Form

Home Address: Street # & Street Name *

Child's Name

Group ID#:

Parent(s) Email: *

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

Child's Date of Birth

Carolina Parenting Solutions, PLLC

Phone: 704-718-8657

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