New Patient Intake Form

To begin therapy services, we will need some additional information from you. Please complete the following form and provide it to your treating clinician at your loved one's first appointment or email the completed form directly to

All forms are in fillable PDF format and can be completed using Adobe Acrobat Reader on your iPad or personal computer.

Therapy Referral Forms

If you are interested in referring a patient to Carolina Therapeutics, PLLC, please fill out a therapy referral form for each patient and return it to our office via facsimile at 980-938-6088 or email at Please include any additional relevant medical records in your possession in order to assist therapists in accurately assessing the patient and forming appropriate treatment plans. If you have any questions about patient referrals to Carolina Therapeutics, PLLC, please contact us at 704-654-8599.