Forms

On this page you will find some forms that we require all patients to read and sign. Each form is specific to the provider you will be seeing. In an effort to save time at your appointment, you will find it very helpful if you can download, print them, and bring the completed form(s) with you to your first appointment. Once you bring the completed forms to your appointment, we can make a copy of them for you, for your records.
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  • Ms. Shelley Chambers
  • Dr. Christine Hook
  • Dr. Ben Rigby
Tab 1
This document outlines our policies and includes a Consent for Treatment that new patients need to be aware of, and sign in agreement. This applies to all patients, children and adults.
If you are coming to our office for therapy, please complete this form and bring it with you. Please complete only if the patient is a child/ minor.
If you are coming for therapy, please complete this form and bring it with you. Please complete only if the patient is an adult.
Please review the HIPPA form and print a copy for your records.
Tab 2
This document outlines our policies and includes a Consent for Treatment that new patients need to be aware of, and sign in agreement. This applies to all patients, children and adults.
If you are coming for psychological testing, please complete this form and bring it with you. Please complete only if the patient is a child/ minor.
If you are coming for psychological testing, please complete this form and bring it with you. Please complete only if the patient is an adult.
Tab 3
This document outlines our policies and includes a Consent for Treatment that new patients need to be aware of, and sign in agreement. This applies to all patients, children and adults.
If you are coming to our office for therapy, please complete this form and bring it with you. Please complete only if the patient is a child/ minor.
If you are coming for psychological testing, please complete this form and bring it with you. Please complete only if the patient is a child/ minor.
If you are coming for therapy, please complete this form and bring it with you. Please complete only if the patient is an adult.
If you are coming for psychological testing, please complete this form and bring it with you. Please complete only if the patient is an adult.
Please review the HIPPA form and print a copy for your records.

2505 S. 17th St., Suite 200, Wilmington . NC 28401 . 910.254.4545 . potentialscenter@gmail.com

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