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

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

Your child's Pediatrician Group?

Zip Code *

Insurance Member ID#:

Home Address: Street # & Street Name *

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.

Group ID#:

Let's Get Started!

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

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

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

Child's Date of Birth

Parent(s) Name(s): *

City or Town *

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)

Client Registration Form

Concerns/Challenges/Problems you are having?

Scheduling Needs?

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

Child's Name

Phone

Additional Information

Parent(s) Email: *