Cynthia Herlong, Phd

Licensed Clinical Mental Health Counselor

Phone: 919-349-2146

Intake Forms

Printable versions of the forms are available below. If your software does not allow you to read them, click here to download the free Adobe Acrobat Reader.


Available At Your First Appointment

The Notice of Privacy Practices (HIPPA) and my Professional Disclosure Statement are available at my office or will be emailed to you for your review.  You will be asked to sign that you have read and agree to these statements at or before your first appointment.

Print All Forms

Print All Forms, Complete, and Bring to 1st Session. You can also fill out, scan and email them back to me or send a cell phone photos of the form(s).

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