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1Date:___Carolina Wellness Psychiatry, LLC INTAKE FORM CONFIDENTIAL Last Name: ___ First: ___ MI: ___ Email address:___ Date of Birth: ___ Age: ___ Sex:___ M ___ F SSN: ___ Mailing Address: ___ City/State:
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Contact Carolina Wellness Psychiatry PLLC office to schedule an appointment.
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Individuals seeking psychiatric evaluation and treatment for mental health concerns.
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People looking for personalized mental health care in the Carolina area.
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Carolina Wellness Psychiatry PLLC is a mental health practice that provides psychiatric services to individuals.
Carolina Wellness Psychiatry PLLC is required to file by the owner or authorized representative of the practice.
Carolina Wellness Psychiatry PLLC can be filled out by providing all necessary information about the practice, including financial details and patient statistics.
The purpose of Carolina Wellness Psychiatry PLLC is to report on the financial status and patient demographics of the practice.
Information such as revenue, expenses, patient visits, and insurance billing must be reported on Carolina Wellness Psychiatry PLLC.
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