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Patient Forms

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New Patient Forms

 

Please review the following documents.

New Client Information

What to do when you arrive, scheduling appointments and how to contact your therapist.

CCS- Southern Pines, NC Office and Cancellation Policies

Information on when and how to cancel an appointment.

HIPAA Information/Notice of Privacy Practices

HIPAA: Health Insurance Portability and Accountability Act…Detailed information about how CCS handles your personal information.

 

Forms that require your information and signatures before being seen: (PDF format) (Please print the following forms, fill them out and bring them to your appointment.)

Registration Form

This form requests client and insurance information.

New Client Signature Page

An acknowledgement of your registration.

Adult Comprehensive Clinical Assessment

Please annotate everything you’re experiencing — this will help start the conversation between you and your new therapist.

Child/Adolescent Comprehensive Clinical Assessment

Please fill in all applicable areas — this will help the counselor/therapist connect with the Child/Adolescent.

Assessment Tool 1: (PHQ-9): A listing and scoring of commonly experienced symptoms.

Assessment Tool 2: (GAD-7): A listing and scoring of commonly experienced symptoms.

 

Other Forms

Authorization to Disclose Medical Information

Patient Rights for Medicaid & Tricare

Confidential / Private Sessions

Carolina Counseling Services – Southern Pines, NC contracts with Licensed professional counselors/therapists/psychologists who provide a friendly, caring, and relaxed atmosphere in the Southern Pines/Pinehurst/Aberdeen/Raeford area. These independently contracted therapists/counselors assist adult individuals, couples, families, and children with resolving issues and getting back to enjoying their lives. Whether you are non-military or military, the independently contracted therapists with Carolina Counseling Services – Southern Pines, NC are able and happy to assist you!

Serving Areas: Counseling Services – Southern Pines, NC

Counties: Moore county, NC, Lee County, NC, Montgomery County, NC, Richmond County, NC, Randolph County, NC, Chatham County, NC

Cities: Southern Pines NC, Pinehurst NC, Aberdeen NC, Taylortown NC, Pinebluff NC, West End NC, Seven Lakes NC, Eagle Springs NC, Ashley Heights NC, Ashmont NC, Five Points NC, Wind Blow NC, Jackson Springs NC, Whispering Pines NC, Vass NC, Cameron NC, Carthage NC, Eastwood NC, Lakeview NC, Narrow Ridge NC, Robbins NC, Roseland NC, Tramway NC, Troy NC, Zion Grove NC, Biscoe NC

We are located at:

Carolina Counseling Services - Southern Pines, NC
780 NW Broad St. Suite 210
Southern Pines, NC 28387

How Do I Set Up my FIRST Appointment?

  • Call: (910) 585-6745 (Fastest way to schedule)
  • Text: (910) 308-3291 (Reply will be via phone)
  • Click here and use our Contact Form (You must include your phone number, because replies will only be made by telephone to ensure security/privacy)
  • Call or Text for your New Patient Appointment Anytime!
  • Appointment scheduling for NEW clients: Mon-Fri 8:30am-5:15pm
  • New client appts may be scheduled when therapists have openings, which may include daytime, evenings and weekends.
  • Established/Standing Appointments are made directly with your therapist!
  • Referrals: MOST beneficiaries do NOT need a Referral!

Choose your Therapist

  • Kristin Vernon, MSW, LCSW

    Specializes in: (Ages 5+) Children, Adolescents, Couples, Families, Anxiety, Depression, Self-Esteem Issues, Grief and Loss, Communication Skills, Divorce, Adjustment Disorders, Mood Disorders, Coping Skills, Parenting, Family Conflict, Marital Conflict, Relationship Issues
    Insurance: BCBS, Tricare, Medicare, cash
    Location: Southern Pines, NC
  • Gretchen Montesanto, MA, LPC, NCC

    Specializes in: (Ages 18+) Teens, Individuals, Anxiety, Depression, Self-Esteem Issues, Grief and Loss, Stress, LGBT, Adjustment Disorder, Motivation, Life Transitions, Mood Disorders, Military Spouses

    Credit Cards: Visa, Mastercard, Discover and American Express

    Location: Southern Pines, NC
    Insurance: BCBS, Tricare and Cash
    Location: Southern Pines, NC
  • Jaime J. Fitzpatrick MS, LPCS, LCAS

    Specializes in: (Ages 18+) Adults, Families and Couples, Anxiety, PTSD, Trauma and Abuse Recovery, Depression, Military Life Issues, Adjustment Disorder, Relationship Issues, Marriage Counseling, Dialectical Behavioral Therapy, Trauma Focused Therapy, Addictions, Emotional Disturbance, Coping Skills, Impulsivity, Grief and Loss, Self-Esteem
    Insurance: BCBS, Tricare and Cash

    Credit Cards: Visa, Mastercard, Discover and American Express

    Location: Southern Pines, NC
  • Kelly ErkenBrack, LCSW

    Specializes in: (Ages 3+) Children, Teens, Adults, Couples and Families. Anxiety, Depression, Grief and Loss, Mood Disorders, Trauma, Adjustments and Life Transitions, ADHD, Behavioral Issues, Parenting, Relationship Concerns, Self Esteem
    Insurance: BCBS, Medicare,  Tricare Prime/Select and Cash

    Credit Cards: Visa, Mastercard, Discover and American Express

    Location: Pinehurst, NC and Southern Pines, NC
  • Kathryn Wiens, PsyD. HSP-P

    Specializes in: (Ages 18+) Adult, Individuals, Couples and Families.
    Insurance: BCBS, Medicare, Tricare Prime/Select, Cash, HSA and FSA accepted

    Credit Cards: Visa, Mastercard, Discover and American Express

    Location: Pinehurst, NC and Southern Pines, NC
  • Tracy Goldberg, MSW, LCSW

    Specializes in: (Ages 5+) Individuals, Adolescents, Adults, Couples, Children and Families. Attention Deficit, Oppositional Defiance, Behavioral Issues, Peer Relationships, Family Conflict, Depression, Anxiety, Parenting Anxiety, ADHD, Self-Esteem Issues, Family Conflict/Divorce, Marriage Counseling, Adjustment Disorders, Relationship Issues, Grief and Loss, Communication Skills, Behavioral Issues, Coping Skills, Mood Disorders, Parent Skill Building, Christian Counseling upon request
    Insurance: BCBS, Tricare, Medicare, Cash, HRA and FSA accepted

    Credit Cards: Visa, Mastercard, Discover and American Express

    Location: Southern Pines, NC