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.

IMPORTANT:  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.  NOTE:  Please read all document categories to determine which forms you will need.

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, 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; the intake form for minors is here)
   

2. •  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.

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

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

3. • Shelton Davis PDS.pdf, Professional Disclosure Statement
   

THIRD, the following forms are used for clients seeking to use insurance coverage.  For your convenience, use the Flowchart or call your insurance carrier 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.

1. •  Insurance Authorization Form.pdf
   

2. •  Insurance Coverage Flowchart.pdf
   

FOURTH, MCCS is HIPAA compliant.  Below is a copy of our HIPAA statement and signatory form.  New clients can either download the statement and form and bring the signed form to the initial session, or a copy of our HIPAA statement will be provided at the initial session.

1. •  HIPAA Statement.pdf
   

If you have any questions about any of these documents, please feel free to discuss them with your therapist.