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
  • Ms. Maddie Haddock
  • Ms. Ella Deaver
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.
If you are coming for an Early Entry to Kindergarten evaluation, this is the ONLY packet you will need to read and sign.
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.
Este documento describe nuestras políticas e incluye un consentimiento para el tratamiento que los nuevos pacientes deben conocer y firmar un acuerdo. Esto se aplica a todos los pacientes, niños y adultos.
If you are coming to our office for therapy, please complete this form and bring it with you.
Si viene a nuestra oficina para recibir terapia, complete este formulario y llévelo con usted.
Please review the HIPPA form and print a copy for your records.
Tab 4
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.

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

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