Pamela Burch, MSW, LCSW

If you are a new client, please complete the appropriate form and bring with you at your first appointment.

• Adult Registration and History
• Child Registration and History
• HIPPA Form
• Consent for Treatment Form
• Release of Information Form

Adobe Reader is required to view these forms. A free version is [ available here ].

A Word About Confidentiality

In order for therapy to be effective, it is imperative that the client feel safe in treatment. Confidentiality means that the information shared in a therapy session will not be shared with any one else with the following exceptions:

1. North Carolina Law mandates that if there is suspicion of abuse and/or neglect of a child under 18 years of age or a disabled adult or an elder adult, a report be made with the County Department of Social Services.
2. If a client presents an imminent danger to his/her own safety or to the safety of another person, hospitalization may be sought or contact made of a family member or other who can provide protection. A potential victim may need to be warned or law enforcement may be contacted.
3. The client has provided written consent to share information with specific individuals/agencies.
4. As provided by the Health Insurance Portability & Accountability Act of 1996 (HIPAA), information can shared with other health care providers who are involved in the treatment; insurance companies to obtain payment, or through a court order.

Your questions regarding Confidentiality are welcomed at your first session and throughout treatment.

"I am so thankful for you Pam. You have helped me through so many difficult times. You have never given up on me. You have challenged me; you have given me wisdom. You have never judged me even when I shared my thoughts and behaviors with you…"

E.L.