Forms

New Patient Form

NEW PATIENT FORM

Emergencies

Emergencies

Our emergency line, (336)-525-9090, is staffed 24/7 for current clients.
Med Visit Form

Treatment Agreement Form

Agreement to treatment with Mood Treatment Center
Controlled Substance Agreement

Controlled Substance Agreement

Med Visit Form

Med Visit Form

Complete before your visit. Or use printable version.
Med Visit Form

Therapy Visit Form

To complete before therapy appointments.
Med Visit Form

Teletherapy Consent Form

Agreement to therapy/counseling through telehealth
Update Demographics

Family & Friends Involvement

Involve Others in Your Treatment
Disability

Disability

Request disability or FMLA forms.
Family involvement

Release of Information

Authorize us to communicate with others on your behalf.
Update Demographics

Request our records

Release our records to other parties.
Legal services

Legal services

For clients who need us to provide testimony or consultation for legal purposes.
Pay bill

Pay bill

Update Demographics

Update Demographics

Authorize us to communicate with your family or friends.
Feedback and Comments

Feedback and Comments

Let us know how we can improve our services.