Documents

The following documents are in Adobe Acrobat (pdf) format. If you do not have Adobe Acrobat installed on your computer, please click the link below to download the free Adobe Acrobat Reader.

Initial Session Documents

FIRST, the documents listed below are necessary for the initial counseling session. They are presented here for the convenience of MCCS clients. Adult clients will need the Intake.pdf and the Covenant.pdf.  For clients who are minors, please complete the MinorIntake.pdf and the Covenant.pdf.  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 (LPC), an additional Professional Disclosure Statement will also need to be read and signed.  Copies are available below or at the therapist’s office.

1. •  Intake.pdf (for adults)
   

2. •  Covenant.pdf (for all clients)
   

3. •  MinorIntake.pdf (for minors)
   

SECOND, the following forms are used for clients seeking to use insurance coverage.  Use the Flowchart to determine coverage. If coverage is available, fill out the Insurance Authorization Form and include a photocopy of your insurance card (front and back).  Bring all documents to your initial session.  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.

1. •  Insurance Authorization Form.pdf
   

2. •  Insurance Coverage Flowchart.pdf
   

THIRD, 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 (PDS).  The Professional Disclosure Statement for several MCCS therapists are listed below.  Please print, read, and sign the relevant document and bring it to your initial session.

1. • Mark Larson PDS.pdf, Professional Disclosure Statement
   

2. • Jonathan Golden PDS.pdf, Professional Disclosure Statement
   

FINALLY, MCCS is HIPAA compliant.  A copy of our Privacy Statement can be found in the .pdf link below.  Your therapist will also provide you with a copy and signatory form.

1. • Privacy Statement.pdf
   

Promotional Literature

These documents are provided for the purpose of raising awareness about the counseling and consultation services provided by MCCS. Permission is granted to print, copy and distribute these materials as needed.

1. • MCCS 101 Reasons.pdf
   

2. • MCCS Doctor Brochure.pdf
   

3. • MCCS Faith Brochure.pdf
   

4. • MCCS Kid Brochure.pdf
   

5. • MCCS Teen Brochure.pdf
   

6. • Samaritan Center Brochure.pdf