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Patient Forms

New Patients

New Patient Forms

 

Please review the following documents.

 

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.)

 

1. Registration Packet

These forms request client and insurance information.

 

2. Adult Comprehensive Clinical Assessment Form

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

 

3. Child/Adolescent Comprehensive Clinical Assessment Form

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

 

Other Forms

Authorization to Disclose Medical Information

Consent for Treatment of Minor Client

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: BCBSTricare Prime/Select, Medicare and Cash
Credit Cards:  
Location: Pinehurst, NC

Counseling Information

How Do I Set Up my FIRST Appointment?

  • Call: 910-687-5034 (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-5pm
  • Established/Standing Appointments are made directly with your therapist!
  • Referrals: MOST beneficiaries do NOT need a Referral!

Other Contact Info

If you have a compliment, concern or comments please contact:

Contact Management: click here

If you need to speak specifically to the owner Click here and use our Contact Form

Carolina Counseling Services – Pinehurst, NC

45 Dowd Circle Suite 5
PinehurstNC 28374