In order to reserve an Initial Evaluation, we require new patients to complete and return:
1. Intake Form (Adult or Child/Adolescent)
2. Demographic Form
3. Practice Policies
4. Financial Policy (Credit Card Form) and HIPAA forms
Optional: Release of Information (if necessary) form.
These should be completed along with a non-refundable deposit of $450.00 (psychiatrist) or $180.00 (therapist) to be applied to your first appointment. These forms are located below. Completed forms may be returned in person to our office, via fax at 803-764-4418, or by mail to 4500 Fort Jackson Blvd, Ste 270, Columbia, SC 29209. Payment can be accepted in person, mailed with forms, or paid over the phone using credit, debit, or health savings account card.
These forms should be completed after your referral from a referring physician, counselor, or therapist has been received and our staff has reached out to you to inform you which provider has accepted you as a patient.
1. Intake Form (Adult or Child/Adolescent)
2. Demographic Form
3. Practice Policies
4. Financial Policy (Credit Card Form) and HIPAA forms
Optional: Release of Information (if necessary) form.
These should be completed along with a non-refundable deposit of $450.00 (psychiatrist) or $180.00 (therapist) to be applied to your first appointment. These forms are located below. Completed forms may be returned in person to our office, via fax at 803-764-4418, or by mail to 4500 Fort Jackson Blvd, Ste 270, Columbia, SC 29209. Payment can be accepted in person, mailed with forms, or paid over the phone using credit, debit, or health savings account card.
These forms should be completed after your referral from a referring physician, counselor, or therapist has been received and our staff has reached out to you to inform you which provider has accepted you as a patient.
Step 1: Please complete the appropriate clinical information form (adult or child/adolescent).
| Adult Intake Form |
| Child Intake Form |
Step 2: Please complete the appropriate demographic information sheet (psychiatrist or therapist).
| Demographic Sheet (Psychiatrist) |
| Demographic Sheet (Therapist) |
Step 3: Please complete appropriate practice policies form (psychiatrist or therapist).
| Practice Policies (Psychiatrist) |
| Practice Policies (Therapist) |
Step 4: Please complete both the financial policy and HIPAA forms.
| Financial Policy (Credit Card Form) |
| HIPAA |
Optional Step: The release of information form only needs to be completed if there is another provider and/or family member you wish our doctor to be able to communicate with regarding your care.
| Release of Information |