Online Admission Forms
Below are links to the admission forms required to be completed for the level of care review and admission process.
Confidential Admission Intake Form
The individual seeking treatment should complete this form to the best of their ability. Can be completed online or over the phone with an admissions coordinator during business hours (M-F, 8-6). Clinical team will review and an intake coordinator will follow-up with care recommendation and next steps.
Authorization to Disclose Healthcare Information
To be signed and filled out by the individual seeking care. If the patient is under 18, a parent or legal guardian must fill out these forms. A separate form is needed for each provider: therapist, psychiatrist, dietitian, physician, past treatment program, primary insurance policy holder, and even family members you would like involved in the admissions process. Providing Carolina House information relating to your eating disorder will help us to create the most appropriate treatment plan for your individual needs.
To be completed by medical provider and sent back to facility via fax (877) 275-7813 or email: CHemail@example.com. Missing requested mandatory labs or labwork older than 14 days may delay the admission process. The PPD test and Hepatitis screenings may be within one year old. *Please let us know if you need a list of potential providers.
Insurance Benefits Questionnaire
Please indicate primary and any secondary/additional insurance information. Insurance information can also be provided over the phone to check benefits and estimate a cost for treatment. Intake will follow-up same or next business day to review insurance coverage and payment options.
Scheduling an Admission
Once medical and clinical approvals have been provided by Carolina House Staff, the admissions team will be able to schedule the admission based on availability.
Please contact us if you have any questions regarding the intake forms or the Carolina House treatment program.
The Carolina House Admissions Team