Plan for Life’s Transitions

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*If you live outside of North Carolina, you must arrange to have your consultation call while physically in the state. Please check with our staff to confirm whether you are attending any virtual meetings from North Carolina. In some cases, in-person meetings may be an option, but availability is limited.

If you do not attend a scheduled virtual appointment while located in North Carolina, you will be charged for the missed session. This is due to licensure restrictions, which require rescheduling the appointment to a time that complies with North Carolina regulations.

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Forms

For Completion Prior to Appointments

(Please be sure to fill out the inquiry form prior to completing the intake packet.)

Adult Forms

• Intake Packet – Adult Testing

• Notice of Privacy Practices

• Good Faith Estimate

If you would prefer to send the below forms via email or fax, download, complete, and send via email to help@drglorigray.com or fax to (704) 765-4749.

Child Forms

(Please be sure to fill out the inquiry form prior to completing the intake packet.)

• Intake Packet – Child Testing

• Intake Packet – Child Therapy

• Notice of Privacy Practices

• Child Developmental and Behavioral Form

• Good Faith Estimate

If you would prefer to send the below forms via email or fax, download, complete, and send via email to help@drglorigray.com or fax to (704) 765-4749.

Please fill out these intake forms within the first week of scheduling your intake. This will allow your clinician time to consult with the referring provider or anyone else with whom you have given permission to share. You may be provided an earlier time if received promptly.

If you would like us to collaborate with a provider, educator, or other member of your service team, parents or adult clients can complete the following form allowing for information exchange: