Documents

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.

These documents will help you with the forms required.

FIRST …

… 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).

SECOND …

… 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.

THIRD …

… 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.

FOURTH …

… 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.

 

Mission Statement

Being dedicated to the healing of heart, mind, and soul, we provide excellent emotional, spiritual, and relational health care to all people of the Carolinas.

Sanctuary Counseling Group is an accredited service center of the American Association of Pastoral Counselors and the Samaritan Institute.