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Forms

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NEW PATIENT FORM

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Emergencies

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

Agreement to treatment with Mood Treatment Center
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Controlled Substance Agreement

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Med Visit Form

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

To complete before medication visits.
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Therapy Visit Form

To complete before therapy appointments.
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Teletherapy Consent Form

Agreement to therapy/counseling through telehealth
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Disability

Request disability or FMLA forms.
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Legal services

For clients who need us to provide testimony or consultation for legal purposes.
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Release of Information

Authorize us to communicate with others on your behalf.
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Request our records

Release our records to other parties.
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Send records to us

Request that outside providers send records to us or communicate with us.
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Pay bill

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Update Demographics

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

Let us know how we can improve our services.

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