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Forms

Demographic Form

This form collects basic contact information and information about services you're seeking.

 

Who should complete?  Everyone seeking services with SLT.

Click to submit this form.

HIPAA & Privacy Practices

This form asks you to sign of on acknowledgement of your rights with respect to confidentiality and your Protected Health Information (PHI).

 

Who should complete?  Everyone seeking services with SLT.

Click to submit this form.

Insurance Agreement

This form asks you to acknowledge your intent to use insurance as a means for covering the costs of your services.

 

Who should complete?

Anyone wishing to use insurance as a payer.

Click to submit this form.

Client Services Agreement

This form is for patients seeking private individualized therapy and coaching.  It is not necessary for DWI related services.

Who should complete?

Anyone seeking individual counseling or coaching services with SLT.

Click to submit this form.

Client Rights

This form asks you to sign off on acknowledgement of your rights in working with SLT.  It also gives contact information for reporting grievances to our professional boards.

Who should complete?  Everyone seeking services with SLT.

Click to submit this form.

BCBS Release of Information

This form asks you to initial and sign off on the minimum necessary information in order for us to coordinate with you insurance company. 

 

Who should complete?

Anyone wishing to use insurance as a payer.

Currently we are only in network with Blue Cross & Blue Shield and this form is specific to BCBSNC.

Click to submit this form.

DWI & Court-Related
Release of Information

This form asks you to initial and sign off on the minimum necessary information in order for us to coordinate with the legal system on your behalf.

Who should complete?

Anyone referred by a lawyer or in need services for court related reasons such as DWI or possession charges

Click to submit this form.

DWI Transfer from Another Provider

This form is a release of information that asks you to initial and sign off on the minimum necessary information in order for us to coordinate with another provider

Who should complete?

If you received an assessment and/or started services with another company but would like to switch to Silver Lining Therapy to complete ADETS, Prime For Life, or Group classes.

Click to submit this form.

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