If you would like the opportunity to read and fill out forms prior to your first appointment, please select which heading applies to you, and fill out the forms listed. If you have Medicaid as your insurance, please also complete the forms under that heading. Otherwise, please arrive about 15-20 minutes early and we will give you the forms upon your arrival to our office and ask you to complete them in our waiting room. We do understand it's a lot of paperwork, but it's become necessary in the current insurance and HIPPA environment.

 

ADULT FORMS
Please download and complete all forms
Client demographics and consent Forms - Adult
Reason for referral, history and symptoms
Medication record
CHILD/ADOLESCENT FORMS
Please download and complete all forms
Client demographics and consent forms - Child/Adolescent
Reason for referral, history and symptoms
Medication record
MEDICAID CLIENTS ONLY FORMS
Please download and complete all forms, choosing Adult or Child/Adolescent as appropriate
Client demographics and consent forms - Adult
Client demographics and consent forms - Child/Adolescent
Self Assessment
Medicaid Attestation
NC DHHS Clients' Rights
Emergency Procedures (please print this and keep it in case of an emergency)
JOHN L HOLT, LPC
If you are seeing John please download this form as well
LPC professional disclosure statement
DEBI PRUITT, LPCA
If you are seeing Debi please download these forms as well
LPC professional disclosure statement
Recording consent form
 
 

          CORNERSTSONE PSYCHOLOGICAL SERVICES - 2711A PINEDALE ROAD, GREENSBORO, NC 27408 - [P] 336.540.9400 - [F] 336.540.9454

      CORNERSTONE PSYCHOLOGICAL SERVICES - 2711A PINEDALE ROAD, GREENSBORO, NC 27408 - [P] 336.540.9400 - [F] 336.540.9454