Not In Network Couples Intake, Deborah

Please download and print the files on this page after scheduling your initial couples counseling appointment with your therapist. Please be sure that BOTH of you complete all of the forms and that BOTH sign the HIPAA form on the back page. Pay close attention that BOTH of you fill in all the starred blanks on the “No Surprise Billing form. Some of the required information on that form will be redundant but we are following federal regulations.

Scan all your images into ONE continuous pdf file (Adobe Scan can do this easily). Submit your pdf file with the secure file transfer mechanism at the bottom of this page. Alternatively you can snail-mail the documents to our office:

Cary Counseling Center

875 Walnut Street Suite 275

Cary, NC 27511

Couples Registration

Couples Service Agreement

Shared Information Authorization

Couples HIPAA Form

No Surprise Billing

Safety&Symptoms

Please print 2 copies of the Safety & Symptoms form to be filled out by both partners

Please use the following file transfer mechanism if you choose to send files over the internet to your therapist. DO NOT USE REGULAR NON-SECURE EMAIL. Attach your file(s) at the very bottom and make sure you add your therapist’s name in the comments section to assist our routing.