Carolinas Center for Evaluation and Treatment

Carolinas Center for Evaluation and Treatment Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Preferred Pronouns

State where you currently reside

Reason for care

What brings you here today?

Anxiety Attentional difficulties Social discomfort Depression Burnout Relationship issues Parenting struggles Trauma Substance misuse It's alot of things

What services are you interested in?

Psychological / Diagnostic Evaluation Educational Evaluation Individual Therapy Couples Therapy Family Therapy EMDR Safe and Sound Protocol Parent-Child Interaction Therapy (PCIT) It's something else

Tell us a little about your mental health journey.

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Referral source

How did you hear about us?

Billing & Payment

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How do you hope to pay for services?

If you intend to use health insurance for services, please provide the name of the insurance carrier and plan name.

Client Preferences

Preferred clinician

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Are you currently involved in or reasonably anticipate involvement in any legal proceedings, including but not limited to custody and civil matters?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.