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
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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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Email
*
For appointment reminders, TeleMedicine invitation links, and patient portal account access. NOT used for newsletters, spam, junk, advertisements, or ANYTHING made to exploit your information and privacy.
How can we help?
*
Medication Management
Therapy/Counseling
Psychological Testing
Addiction Treatment (i.e.: Suboxone)
Reason For Appointment
*
Primary Insurance
*
MEDICAID
MEDICARE
BCBS
AETNA
OTHER
NONE
Other Insurance
*
Primary Insurance ID
*
Take Picture of Primary Insurance Card or Use Existing Picture of Insurance Card (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
*
MEDICAID
MEDICARE
BCBS
AETNA
OTHER
Other Insurance
*
Secondary Insurance ID
*
Take Picture of Insurance Card or Use Existing Picture of Insurance Card (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.
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