Documents
The following documents are in Adobe Acrobat (pdf) format. If you do not have Adobe Acrobat installed on your computer, please click the Adobe link below to download the free Adobe Acrobat Reader.
Initial Session Documents
These documents are presented for your convenience and to save time during your initial appointment. Print them, fill them out, and bring them with you to your first session.
FIRST, both 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.
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• Intake.pdf (for adults; the intake form for minors is here)
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• Covenant.pdf (for all clients)
SECOND, 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.
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• Mark Larson PDS.pdf, Professional Disclosure Statement
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• Jonathan Golden PDS.pdf, Professional Disclosure Statement
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• Marilyn Cirulis PDS.pdf, Professional Disclosure Statement
THIRD, 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 the authorization form and photocopied card 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.
