EACH PERSON ATTENDING COMPLETES A SEPARATE INTAKE FORM.
 
  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

CONFIDENTIAL CLIENT INFORMATION

    
 
 
 
Date of Birth:  
 
 
 
     
 How do you prefer we contact you?(Mark all that apply)        
 
Only Add Numbers that you want to receive a message to: (voice/text)
 
 
 
 
 
 
 
 
 
 
 
 


 
Legally Responsible Person ( For Minor Clients)[SWTC must have a copy of official custody documents on file prior to serving a minor]
 
 
 
   

 
 

Please check all that apply in your current family (only yourself, spouse, and/or kids). History of:
 
 

Please check any/all that apply anywhere in your family tree (your parents, relatives, spouse's family, etc.). History of:
     
 
 
 Current Medications, include name of medication, start date, reason, dosage, and prescribing doctor:
Please list previous counseling, include name, dates attended, reason and diagnoses
 
Please briefly describe what you hope to accomplish as a result of working with your therapist:
 
Please briefly describe why you chose SWTC over another therapy practice:
 
How did you come to hear about Shelby Wellness and Therapy Center? (check all that apply)
                     
Please list below any internet search engines or websites you visited in your therapist search:
      
 
Please check any/all issues which are a concern for you today:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What do you consider your strengths?
 
What do you consider your areas of improvement?
 


RESPONSIBILITY FOR
APPOINTMENTS & CANCELLATION POLICY

An important part of the therapy process is the acceptance of responsibility for making and keeping appointments. Community Wellness Partners of NC, PLLC (CWPofNC) offers appointment reminders. However, it is still the client’s responsibility to be present for appointments even in the rare case that the appointment reminders are not functioning properly or if the client chooses to opt out of text/voicemail/email reminders. Clients are encouraged to be responsible for keeping up with appointments in a personal calendar or journal. Recurring appointments are offered as a benefit to active clients whose accounts are in good standing. This privilege is available on a first come, first served basis, but recurring appointments must have a calendar end-date no more than six weeks into the future. Therefore, clients are responsible to renew recurrences whenever necessary. CWPofNC makes every effort to provide clients with chosen appointment times and reserves that time for their appointment alone.

   We are reasonable to allow unavoidable cancellations due to a true emergency or illness. However, we charge the full session fee for appointments cancelled or missed with less than 24 business hours' notice ($110.00 for intakes and $75.00 for follow ups). We require cancellations/reschedule notice of 48 hours before on evening and weekend appointments. These times are highly requested and provided as a convenience to clients in good standing who are willing to provide NON-refundable PRE-PAYMENT. Clients are always responsible for the total balance for and services rendered regardless of insurance coverage.   If you are late 16 minutes or more past appointment., time is considered a “No Show”. Since late/ missed appointments are not covered it is the client’s responsibility to pay. If you miss 2 appointments without proper communication as our policy requests, you will be terminated from Community Wellness Partners of NC as a client. If you have Medicaid it is your responsibility to provide primary insurance information. If you fail to provide primary insurance, you will be responsible. Medicaid will not pay.

BUSINESS HOURS
Regular Business hours: Monday through Friday 9am-5pm.
Afterhours/Weekend Hours:  Tuesday, Wednesday, and Thursday 5pm-8pm, Saturday 9am-4pm.
If a scheduled appointment is Monday at 3pm, a client should cancel by Sunday, no later than 3pm, to avoid the missed session fee. If an appointment is scheduled for 10am on Wednesday, the client must cancel by no later than 10am Tuesday. Messages left on the CWPofNC voicemail do count as adequate cancellation if the time stamp indicates the message was left 24-hours before. CWPofNC does not schedule appointments through the internet or email. Attempts by clients to change or cancel appointments this way will not be considered valid.

Credit Card Policy
I understand this policy and authorize Community Wellness Partners of NC, PLLC, to assess cancellation and no-show fees according to the above outlined policy to the credit card listed below. If the patient has Medicaid or NC Healthchoice insurance you do not need to provide credit card information.

















If you have Medicaid it is your responsibility to provide primary insurance information. If you fail to provide primary insurance, you will be responsible for the charges. Medicaid will not pay.