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

Zip Code *

Medicaid Member ID#:

Home Address: Street # & Street Name *

Please complete this application if your family is either uninsured, or Medicaid/EBT eligible in Mecklenburg, Union, and Cabarrus counties and are unable to pay out of pocket for these parent training classes.

Child's Date of Birth

Parent(s) Name(s): *

City or Town *

Triple P Scholarship Application

Concerns/Challenges/Problems you are having?

Parent(s) Name(s):

Type of Child's Insurance Plan?

NC Medicaid

SC Medicaid

None of the above

Child's Name

Phone

Additional Information

Parent(s) Email: *

Costs & Coverages
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