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)

Initals:

Responsibility for Appointments and the Cancellation Policy

Initals:

Business Hours

Initals

A Note Regarding Children/Minors

Initals:

Time of Appointments

Initals:

Check-in/Payments

Initals:

Fees

Initals:

Payment and Billing

Initals:

Insurance/Third Party Reimbursement

Initals:

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)

Initals:

Potential Risk/Alternative Treatments

Initals:

Consent to Treatment

Initals:

Results/Outcomes and Termination

Initals:

Confidentiality

Initals:

Client’s Request for Information

Patient Name:

Signature of Client/legal Guardian