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Intake Forms

Instructions:
1) DOWNLOAD the form(s) you need by clicking a link below
2) SAVE the file to your computer
3) EMAIL completed forms to intake@fspcares.org

Combined Intake Packets
Intake Packet Adult (Part 1)
Intake Packet Adult (Part 2)

Intake Packet Child (Part 1)
Intake Packet Child (Part 2)

Individual Forms
GAIN-SS
Burns Checklists
CAGE-AID
Child Assessment
Consent To Release Information – Sandhills
Consent to Release Information
Basic Assessment
Agreement to Pay
WHODAS
Telehealth Informed Consent
URICA
Rights and Notices
NC-TOPPS
General Referral Form
Substance Abuse Pretest
TB Screening
Group Referral
Group Information
Informed Consent for Service
In Loco Parentis

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Responsive web design by Trone Brand Energy | Confidential Policy & Procedures

Disclaimer: The diagnosis and treatment of psychiatric disorders requires trained professionals. The information provided here is to be used for educational purposes only. It should not be used as a substitute for seeking professional care for the diagnosis and/or treatment of any mental or psychiatric disorder.

Activity on third-party websites and applications is subject to third-party privacy and/or data policies, which may override this organization’s own privacy policy.