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 (non-Medicaid)
Please click the link below, download and complete all forms
Client Intake Forms - Adult
CHILD/ADOLESCENT FORMS (non-Medicaid)
Please click the link below, download and complete all forms
Client Intake Forms - Child/Adolescent
MEDICAID CLIENT FORMS
Please click the links below, download and complete all forms, 
choosing Adult or Child/Adolescent as appropriate then Self Assessment
Client Medicaid Intake Forms - Adult
Client Medicaid Intake forms - Child/Adolescent
Self Assessment
JOHN L HOLT, LCMHC
If you are seeing John please download this form as well
LCMHC professional disclosure statement
DEBI PRUITT, LCMHCA
If you are seeing Debi please download these forms as well
LCMHCA 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