Community Wellness Partners of NC PLLC
809 N. Lafayette St., Suite A, Shelby, NC  28150
1446 E. Gaston St. Suite 101, Lincolnton, NC 28092
           
Phone: (704) 284-0554
Email: info@cwpofnc.com

PLEASE READ AND KEEP THE “NOTICE OF AGENCY POLICIES AND PROCEDURES” BROCHURE

 I have read and agree to the “Notice of Agency Policies and Procedures” brochure of Community Wellness Partners of NC PLLC dba Shelby Wellness and Therapy Center, that has been provided for me; if it has not been provided to me I have had opportunity to request and receive one.

I have read and agree to the terms of the following sections of the agency policies and procedures area of the brochure

 
 (please initial beside each section)
 
 
Responsibility for Appointments and the Cancellation Policy
 
 
Business Hours
 
 
 A Note Regarding Children/Minors
 
 
Time of Appointments
 
 
 Check-in/Payments
​​​​​​
 
 Fees
 
 Payment and Billing
 
 
 Insurance/Third Party Reimbursement
 
 
 Electronic Communication
 

I have read and agree to the terms of the following sections of the informed consent areas of the brochure

  (please initial beside each section)
 
 
​​​​​​Potential Risk/Alternative Treatments
 
 
Consent to Treatment
 
 
Results/Outcomes and Termination
 
 
Confidentiality
 
 
Client’s Request for Information
 

 
 
 
 Signature of Client/legal Guardian