FORMS
Disclosure Statement & Referral Forms
Referral forms are available for download in both Acrobat PDF and Microsoft Word formats. Links will open in a new window or tab.
Disclosure Statement
A. Watson – Disclosure Statement.pdf
A. Watson – Disclosure Satement.doc
S. Warren – Disclosure Statement.pdf
S. Warren – Disclosure Statement.doc
G.Pttman – Disclosure Statement.pdf
G.Pittman – Disclosure Statement.doc
A. Bass – Disclosure Statement.pdf
A. Bass – Disclosure Statement.doc
K. Womble – Disclosure Statement.pdf
K. Womble – Disclosure Statement.doc
M. Rascoe – Disclosure Statement.pdf
M. Rascoe – Disclosure Statement.doc
A. Watson – Disclosure Satement.doc
S. Warren – Disclosure Statement.pdf
S. Warren – Disclosure Statement.doc
G.Pttman – Disclosure Statement.pdf
G.Pittman – Disclosure Statement.doc
A. Bass – Disclosure Statement.pdf
A. Bass – Disclosure Statement.doc
K. Womble – Disclosure Statement.pdf
K. Womble – Disclosure Statement.doc
M. Rascoe – Disclosure Statement.pdf
M. Rascoe – Disclosure Statement.doc
Client Referral Form
Client Release of Information Form
CONTACT INFORMATION
*EFFECTIVE 10/1/2021 NEW LOCATION
4003 Nash Street NW | Wilson, NC 27896
Office Phone: 252-640-2493
Mobile Phone: 252-245-1876
Email: [email protected]
HOURS:
Mon-Fri and Weekends (Hours may vary)
ACCEPTED INSURANCE:
Blue Cross/Blue Shield
United Health Care
Cigna
EAP (ComPsych , McLaughlin Young)
UMR Insurance
Optum
Medcost
Aetna
Medicare
SCHEDULE APPOINTMENT:
Call office or mobile phone to schedule