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Patient Forms

What to expect on your first visit

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.

 

Other Forms

Authorization to Disclose Medical Information

Rose Thomas, MA, LPC, LCAS, NCC

Specializes in: (Ages 5+) Children, Teens, Individuals, Couples and Families. Anxiety, Depression, ODD (Oppositional Defiance Disorder, ADHD, Relationship Issues, Marriage Counseling, Parenting, PTSD/Trauma Recovery, Acute Stress Disorder, Adult Sexual Abuse Survivors, Adjustment Disorders, Depressive Disorders, Persistent Depressive Disorder, Bipolar and Related Disorders, Self-injurious/Self-Harm, Generalized Anxiety Disorder, Panic Disorder, Agoraphobia, Separation Anxiety, Disruptive Disorders, Conduct Disorder, Marital Conflict and Discord, LGBT, Substance Use Disorders
 Insurance: BCBS, Tricare, Tricare Prime, Tricare Select, Extra, Retired, Cash, HSA and FSA accepted (credit cards accepted)
 Credit Cards: Visa, Mastercard, Discover and American Express

 

 
Specializes in: (Ages 4+) Children, Individuals, families, PTSD, Trauma, Eye Movement Desensitization and Reprocessing (EMDR) Adjustment Disorder, ADHD, Depression, Anxiety, communication skills, and Parenting Skills, Aggression, Behavior Management, Life transitions, Family Conflict, Difficulty Coping, Relationship Problems, Depression, Anxiety

InsuranceBCBSTricare, Cash, HSA and FSA accepted and Apple Pay
 
Credit cards:  

 

Carolina Counseling Services - Cameron, NC
Shirlisa Daniels, MS, LPC, NCC

 

Often in our busy lives we all find ourselves feeling stuck and needing to speak to someone. Someone to share our hopes and goals as well as our fears and doubts. I strive to create an environment of acceptance and a safe place to discuss your innermost feelings and emotions.

My goal is to provide you with an encouraging, safe, and judgment-free environment where you can talk freely about what you’re experiencing and learn how to work with those issues and concerns so that you can function better in your life. Call me today so we can begin our journey together.

Specialties/ Issues: Children 4+, Teens, Adults and Individuals, Families, Anxiety Disorders, Depression, Panic Disorder, Bipolar Disorder, ADHD, ODD, PTSD, Relationship Issues, Conflict Resolution and Life Transitions.

Personal Information: In practice since 2013; Schools: University of Alabama; Graduated 2008, Texas A&M University-Central Texas; Graduated 2013. Licenses: North Carolina, #13332

Insurance Accepted: BCBS, Tricare Select, Cash

Location: Cameron NC, (near Lexington Plantation). Hwy 87.

How Do I Set Up my FIRST Appointment?

  • Call: (910) 722-9008 (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-5:15pm
  • New client appts may be scheduled when therapists have openings, which may include daytime, evenings and weekends.
  • Established/Standing Appointments are made directly with your therapist!
  • Referrals: MOST beneficiaries do NOT need a Referral!
Carolina Counseling Services - Cameron, NC
35 Plantation Drive, Suite 100B and 100C
Cameron, NC 28326

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