Prior to Your First Session …
Sanctuary Counseling Groups requires a number of forms in order to best serve the needs of our clients. These documents in .pdf format are presented for your convenience and to save time during your initial appointment. Print them, fill them out, and bring them with you to your first session.
NOTE: Please read all four document categories to determine which forms you will need.
This document will help you with the forms required.
- Paperwork Checklist - This may help manage the forms needed.
… the documents listed below are necessary for the initial counseling session. Adult clients will need the Intake Form and the Covenant. Please print these documents, complete and sign them, and bring them with you to your initial session. Depending on the professional credentials of the therapist, an additional Professional Disclosure Statement will also need to be read and signed (see below).
- Intake Form — Required for all adult clients.
- Counseling Covenant — Required for all clients.
- Medications — Required for all clients (if applicable).
- Letter from our Executive Director and Board; please read as part of your informed consent.
- Demographic Information — For all clients; this will help us provide the best care that we can. The form is totally anonymous.
- Survey Permission Form —For all clients; this form gives or withholds permission to include you in our client satisfaction survey.
… in addition to the above documents, therapists who are NC Licensed Professional Counselors (LPC) also require that clients review and sign the therapist's Professional Disclosure Statement. The Professional Disclosure Statement for several SCG therapists are listed below. Please print, read, and sign the relevant document and bring it to your initial session.
- Mark Larson PDS (NC LPC) — Professional Disclosure Statement
- Jonathan Golden PDS (NC LPC) — Professional Disclosure Statement
- Shelton Davis PDS (NC LPC) — Professional Disclosure Statement
- Shannon White PDS (NC LPC) — Professional Disclosure Statement
- Jay Cobb PDS (NC LPCA) — Professional Disclosure Statement
- Patricia Hawkins Wells PDS (NCFBPPC) — Professional Disclosure Statement
- Stacey Watkins-Griffith PDS (NCFBPPC) — Professional Disclosure Statement
… the following forms are used for clients seeking to use insurance coverage. Use the Flowchart or call your insurance carrier to determine coverage. If coverage is available, fill out the Insurance Authorization Form and include a photocopy of your insurance card (front and back), and bring them to your initial session. It is strongly recommended that new clients contact our Central Office (704-375-5354) to confirm insurance availability, deductible, and co-pay prior to your first session. If your therapist is not in your insurance panel and you still wish to file insurance, we will provide a super-bill that you can send to your insurance company for reimbursement. However, you will be responsible for the full fee at time of service. NOTE: For insurance purposes, a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) diagnosis is given and becomes part of your permanent medical record.
- Insurance Authorization
- Insurance Coverage Flowchart, (offered for your benefit in assessing coverage)
… SCG is HIPAA compliant. Below is a copy of our HIPAA statement and signatory form. New clients can either download the statement and form and bring the signed form to the initial session, or a copy of our HIPAA statement will be provided at the initial session.
In addition, if you would like Sanctuary Counseling Group to maintain a credit card number for you in order to manage fee payment, use the form below.
If you have any questions about any of these documents, please feel free to discuss them with your therapist.