Forms for New Patients
For your convenience, we have provided our forms below. After you have scheduled your appointment, please complete and submit the following forms. If you have not yet scheduled your appointment, please do so prior to completing submitting these forms.
An accurate and thorough assessment during the intake appointment is vitally important to the overall success of subsequent mental health diagnosis and treatment. As such, intake appointments are around 1.5 hours, so please plan accordingly.
We have provided the required intake forms below for your convenience (online or printable). Filling out these forms in advance and bringing them with you to your initial appointment will help speed up the intake process.
Required Forms
OPTIONAL FORMS
If you do not have insurance, or are not covered by one of our accepted plans, and would like to apply for our income-based sliding fee scale, please complete the application below. It may be completed digitally, or printed out and faxed to 704-547-3150.
A copy of your insurance card and photo ID / driver’s license will need to be emailed to newpatients@cehcharlotte.com.
If you prefer to complete your forms manually, please download and print the following forms. Once they are completed, you may scan and email them to newpatients@cehcharlotte.com, fax them to (704) 547-3150, or simply bring them to your initial visit.