Part 1 - Intake Request / Request to Schedule

If this is an emergency, please call 911.
Have you ever been seen by a provider at Carolina Behavioral Care? *

No Yes
Please verify that you are human *

New Patient Intake Request

If this is an emergency, please call 911.
Request to Schedule an Appointment

To use this, you must have been seen by a Carolina Behavioral Care provider at least once.
Are you the patient's legal guardian?

Yes No
Your Name *

First Name Last Name
Phone Number *
Patient Name *

First Name Last Name
Birthday *

Month Day Year
Date
Birth Sex *

Female Male
Address *

Street Address

Apt / Suite #

City State

Zip Code
Phone Number *
Email *
example@example.com
How can we help? *

Medication Management Therapy/Counseling Psychological Testing Addiction Treatment (i.e.: Suboxone)
Reason For Appointment *
Primary Insurance *
Other Insurance *
Primary Insurance ID *
Take Picture of Insurance Card or Use Existing Picture (Upload)?

Take Picture Use Existing Picture (Upload)
Picture of the FRONT SIDE of Your Primary Insurance Card
Picture of the BACK SIDE of Your Primary Insurance Card
Upload Pictures of Your Primary Insurance Card (Both Sides Please)

Browse Files
Please include the front and back. Cancel of
Do you have a Secondary Insurance Provider?

Yes No
Secondary Insurance *
Other Insurance *
Secondary Insurance ID *
Take Picture of Insurance Card or Use Existing Picture (Upload)?

Take Picture Use Existing Picture (Upload)
Picture of the FRONT SIDE of Your Secondary Insurance Card
Picture of the BACK SIDE of Your Secondary Insurance Card
Upload Pictures of Your Secondary Insurance Card (Both Sides Please)

Browse Files
Please include the front and back. Cancel of
Completing these forms does not guarantee an appointment with our office. Your information will be reviewed by our staff. Upon approval, our staff will reach out to you to schedule an appointment. *

I have read and understand the above information.
Should be Empty:

New Patient Intake Request

Request to Schedule an Appointment