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 Please review the New Client Forms below; complete the Information/Acknowledgement/Consent provided below prior to your first therapy session so time will not be spent filling out forms during your appointment.

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**We do not accept EAP nor do we complete any Medical Excuses,  Leave or Workers' Comp Claims

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*Attention Clients: Once you've set up an appointment, please check your email for a Therapy Notes Client Portal access message  where you will be able to create a login.​*

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Welcome to our appointment scheduling information. Clients of John Goodwin III. can conveniently request appointments through the Client Portal.

 

However, clients of John Burton Jr. are kindly asked to call 980.202.AMEN (2636) to arrange their appointments. Thank you for your cooperation!

Client Information/Acknowledgement/ Consent

Please fill out the following form.

John W. Goodwin III.

John Burton, Jr.

Can we leave a message on the number provided concerning scheduling and other matters?
Can we leave a message on the number provided concerning scheduling and other matters?
Will you be using insurance?
Upload Insurance Card (back/front)
Upload supported file (Max 15MB)
By signing below, you are indicating that you have read and understand the information contained in this contract that you have obtained a copy from the website, and keep for your records. All questions you have about this statement have been answered to your satisfaction.
I acknowledge that I received and have been given an opportunity to read a copy of Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I may contact atalkwithjohn@gmail.com or at (704) 412-1407.
I acknowledge that I received and have been given an opportunity to read a copy of the Teletherapy informed Consent from. I understand that if I have any questions regarding the form, I may contact atalkwithjohn@gmail.com or at (704) 412- 1407.

Thank you for submitting!

*Patient Waiting List:
(If an appointment is unavailable and you would like to be added to the waiting list)

2015 Ayrsley Town Blvd.

Suite 202

Charlotte, North Carolina 28273

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Tel: (704) 412-1407

Fax:(704) 971-9192

Email: atalkwithjohn@gmail.com

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Psychology Today (Link) 

Mon - Friday: 7:00am - 7pm

​Saturday:  Closed

​Sunday:   Closed

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A Talk with John Counseling and Consulting, PLLC

Therapy for Individuals, Couples and Families

Charlotte, North Carolina

© 2020 by A Talk with John Counseling and Consulting, PLLC. Proudly created with Wix.com

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