Our paperwork is required to be filled out in full before your first scheduled appointment. It’s important for you to complete the paperwork before you arrive so you can spend your scheduled time with your clinician, not filling out forms. If you are not able to print these forms, we ask that you arrive no later than 30 minutes before your first appointment so that you have time to fill them out before your scheduled visit. When you schedule your first appointment, a member of our administrative staff can email you the specific forms you’ll need for your appointment.

Mental Health & NutrrCounseling Forms

• Adult Intake
• Child & Adolescent Intake
• Couples Intake (This packet must be completed separately by each partner)

Bariatric Surgery Patient Forms

• Bariatric Intake

Perinatal Forms

• Perinatal Intake Forms

Medication Management Forms

Please note: Clients who are being seen for Medication Management must have their intake forms submitted NO LATER than 48 hours, or 2 business days, in advance to allow our provider enough time to review client forms. If forms are not submitted ahead of time for Medication Management, the appointment will be canceled, and the client will be rescheduled once the forms are submitted.

• Medication Management Intake

Notice Of Privacy Practices

• Privacy Policy and HIPAA Statement – Confidentiality is very important to us. We hope that you will read over this information to familiarize yourself with our policies that protect your private health information. You will find an acknowledgement of receipt for these practices in your packet listed above.

Other Forms

• Release of Information (ROI) – To ensure our client’s confidentiality, protected health information is not shared without written consent from our client or their guardian (unless a client is deemed an immediate risk to self or others). This form is used so that providers can communicate with one another via phone, fax, or email.
• Rights and Consent to Treatment

If there are any questions about these policies, please contact our office manager, Macon Funderburk, admin@chrysaliscenter-nc.com.

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