Forms & Insurance

Name: One-Eighty Counseling
Address: 69 Shipwash Drive, Garner, NC, 27529
Telephone: (919) 772-1990

Please download and complete our intake packets and wellness forms. You may submit them below, e-mail them to jenniferlatsha@one-eightycounseling.com or bring them with you completed to your visit. Filling out these forms will greatly reduce waiting times. Thank you for choosing us and we hope to see you soon.

***Forms Require Adobe Acrobat in Order to View or fill out on your local computer as well as to Print. Click here for Adobe

See below to download individual New Patient Forms

or

download the packet containing the intake forms and behavioral forms

Otherwise

Download All New Patient Forms here

Download Packet |Adult Intake & Behavorial Forms

Download Packet |Minor Intake & Behavorial Forms

After you have filled out a form, be sure to save it. Then, please use the drop box provided here to submit your completed form(s).

Name*
First Last
Email
*
Drop files here or

Accepted file types: pdf, png, gif, jpg.
Phone
This field is for validation purposes and should be left unchanged.

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Intake Fillable Form | Children and Adolescents

After you download this form, you are able to complete it in on your computer using Adobe Reader.

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Intake Fillable Form | Adults 18 years & older

After you download this form, you are able to complete it in on your computer using Adobe Reader.

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Behavioral Health Medical Provider Communication

After you download this form, you are able to complete it in on your computer using Adobe Reader.

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UBH Wellness Assessment | Youth

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UBH Wellness Assessment | Adult

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Notice of Privacy Practices

Aviso de Practicas de Privacidad

Insurance

Our providers are In-Network with a number of Insurance companies including:
> Aetna
> Blue Cross / Blue Shield
> Cigna
> MedCost
> Optum/United Behavioral Health
> State Employees Health Plan
> United Healthcare
> UMR

We also offer options for out of network insurance coverage and self-pay.

*Full payment is due at the time of service.

Please contact your insurance company to determine your policies benefit coverage for Mental/Behavioral Health/Substance Abuse in an office place of service (outpatient) setting.

EAP: We are contracted with several companies Employee Assistance Programs (EAP). Please provide the EAP group name, company name, authorization number and forms for reimbursement.

For questions about the forms or insurance, you may call Jennifer Latsha, our Practice Manager with One-Eighty Counseling and she will assist you, or you may call your insurance provider directly.

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