Providers

Please review and download the forms below. Feel free to use your own forms for client intake and assessment and for progress notes. Complete and return the forms via mail or fax (919-850-9825) at case closure along with your client intake and assessment notes. Please do not return the forms via email. Thank you for your assistance with this referral.

The following forms are available for download:

• Affiliate Reimbursement Form (PDF 53KB)
• Client Intake and Assessment Form (PDF 44KB)
• Closing Data Sheet (PDF 15KB)
• Confidential Information for Our Records (PDF 19KB)
• Freedom of Choice Affidavit (PDF 10KB)
• Statement of Understanding (PDF 14KB)
• Notice of Privacy Practices (PDF 22KB)
• Authorization for Release of Confidential Information (PDF 16KB)
• Symptom Checklist (PDF 78KB)