Back to homepage

Patient Forms

New Patients

New Patient Forms


Please review the following documents.

New Client Information

What to do when you arrive, scheduling appointments and how to contact your therapist.

CCS Office and Cancellation Policies

Information on when and how to cancel an appointment.

HIPAA Information/Notice of Privacy Practices

HIPAA: Health Insurance Portability and Accountability Act…Detailed information about how CCS handles your personal information.


Forms that require your information and signatures before being seen: (PDF format) (Please print the following forms, fill them out and bring them to your appointment.)

Registration Form

This form requests client and insurance information.

New Client Signature Page

An acknowledgement of your registration.

Adult Comprehensive Clinical Assessment

Please annotate everything you’re experiencing — this will help start the conversation between you and your new therapist.

Child Adolescent Comprehensive Clinical Assessment

Please fill in all applicable areas — this will help the counselor/therapist connect with the Child/Adolescent.


Assessment Tool 1: (PHQ-9): A listing and scoring of commonly experienced symptoms. 

Assessment Tool 2: (GAD-7): A listing and scoring of commonly experienced symptoms.

Assessment Tool 3: (PCL-C): PTSD CheckList – Civilian Version


Other Forms

Authorization to Disclose Medical Information


Gail Gustafson, MSW, LCSW

Specializes in: (Ages 9+) Adolescents and Adults, Individuals, Couples and Families. PTSD/Trauma, EMDR, Adoption, Drug/Alcohol/Substance Abuse addiction, Anxiety, Depression, Bi-polar, Life Transitions, Grief and Loss, Parenting, Family, couples and marriage counseling.
 Insurance: BCBS, Tricare/ Tricare Prime Tricare Select/Extra/Retired and Cash (Credit Cards Accepted, HSA and FSA )
 Credit Cards: Visa, Mastercard, Discover and American Express

Counseling Information

How Do I Set Up my FIRST Appointment?

  • Call: (919) 533-3020 (Fastest way to schedule)
  • Text: (910) 308-3291 (Reply will be via phone)
  • Click here and use our Contact Form (You must include your phone number, because replies will only be made by telephone to ensure security/privacy)
  • Call or Text for your New Patient Appointment Anytime!
  • Appointment scheduling for NEW clients: Mon-Fri 8:30am-5pm
  • Established/Standing Appointments are made directly with your therapist!
  • Referrals: MOST beneficiaries do NOT need a Referral!

Other Contact Info

If you have a compliment, concern or comments please contact:

Contact Management: click here

If you need to speak specifically to the owner Click here and use our Contact Form

Carolina Counseling Services - Pittsboro, NC
68 Fayetteville St.
Pittsboro, NC 27312