Child's Date of Birth

Concerns/Challenges/Problems you are having?

Child's Name

Parent(s) Email: *

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?

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)

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

Client Registration Form

Additional Information

Let's Get Started!

City or Town *

Carolina Parenting Solutions, PLLC

Phone: 704-718-8657

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

Zip Code *

Insurance Member ID#:

Group ID#:

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

Phone

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.

Any flexibility in your stated availability?

Scheduling Needs?

Offering:

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

Upload File

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

Your child's Pediatrician Group?

Home Address: Street # & Street Name *

Parent(s) Name(s): *