Client Forms

If you are a current or new patient at Piedmont Counseling Center, these forms are available for download.  These forms can also be filled out during the first session, but it will save time if you would download them and complete them prior to your first session.

If you are a new patient (or considering being a patient at Piedmont Counseling Center), we highly recommend that you register for the patient portal.  This will take the place of completing most forms and will ensure that your information is accurate and up to date.  Registering for the patient portal in no way obligates you and there is no cost involved with using the patient portal.  Your information is encrypted and secure and compliant with privacy regulations.

Patient Contact Information and Communication Preferences – Please download and complete prior to your first session

PCC notice of privacy practices.docx – This document is reference information for you and explains the HIPAA law and how our staff protects your privacy.  There is nothing to fill out, but we recommend that you review this form prior to your initial session.

Release-of-Information – This form is only needed if you would like your clinician to release information or communicate with a third party (for example, your physician, or your employer).


125 Allen Street
Kernersville, NC 27284

(336) 293-7406

Got Questions?
Send a Message!

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.