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Carolina Parenting Solutions, PLLC

Phone: 704-718-8657

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

Type of Card *

Card Number *

Child's Date of Birth *

CVV *

**STOP**

Do not complete these next step forms until or unless, you have been instructed to do so from our Intake Coordinator

&/or

You have been assigned a specific primary therapist and have a initial start date.

Otherwise return to the Contact Us page and complete the Client Registration Form.

I agree to the terms of payment to register my child and family for therapy services with Carolina Parenting Solutions, PLLC. Understand the fee for service rates and agree to move forward. I understand that charges for therapy services are due at the time the services are rendered. *

Yes

Full name as appears on card *

Method of Payment

Child's Full Name *

Expiration Date of Card *

Offering:

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

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