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 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 14 Monckton Blvd Suite 100 A, Columbia, SC 29206. 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 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 14 Monckton Blvd Suite 100 A, Columbia, SC 29206. 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 | |
File Size: | 114 kb |
File Type: |
Child & Adolescent Intake Form | |
File Size: | 78 kb |
File Type: |
Step 2: Please complete the appropriate demographic information sheet (psychiatrist or therapist).
Demographic Sheet (Psychiatrist) | |
File Size: | 94 kb |
File Type: |
Demographic Sheet (Therapist) | |
File Size: | 67 kb |
File Type: |
Step 3: Please complete appropriate practice policies form (psychiatrist or therapist).
Practice Policies (Psychiatrist) | |
File Size: | 68 kb |
File Type: |
Practice Policies (Therapist) | |
File Size: | 66 kb |
File Type: |
Step 4: Please complete both the financial policy and HIPAA forms.
Financial Policy | |
File Size: | 71 kb |
File Type: |
HIPAA | |
File Size: | 61 kb |
File Type: |
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 | |
File Size: | 68 kb |
File Type: |