Call 843-747-5830
  • Contact Us
  • Bill Pay
  • Careers
Palmetto Lowcountry Logo
  • Programs & Services
    • Adult Programs
      • Telehealth
      • Inpatient Treatment
        • General Psychiatric
        • Crisis Stabilization
        • Medical Detoxification
      • Outpatient Treatment
        • Partial Hospitalization Program
        • Intensive Outpatient Program
        • Chemical Dependency Half Day Program
      • Military Personnel Treatment
    • Adolescent Program
  • About Us
    • Meet the Team
    • Facility & Campus
    • Licensing & Accreditation
  • Admissions
    • For Patient & Families
    • What to Bring
    • Visitation
    • Insurance
  • Resources
    • Partnerships
    • Community Resources
    • Release of Information
    • Outpatient Intake Forms
  • Programs & Services
    • Adult Programs
      • Telehealth
      • Inpatient Treatment
        • General Psychiatric
        • Crisis Stabilization
        • Medical Detoxification
      • Outpatient Treatment
        • Partial Hospitalization Program
        • Intensive Outpatient Program
        • Chemical Dependency Half Day Program
      • Military Personnel Treatment
    • Adolescent Program
  • About Us
    • Meet the Team
    • Facility & Campus
    • Licensing & Accreditation
  • Admissions
    • For Patient & Families
    • What to Bring
    • Visitation
    • Insurance
  • Resources
    • Partnerships
    • Community Resources
    • Release of Information
    • Outpatient Intake Forms
Outpatient Intake Formszach.fogleman2022-08-30T14:34:10-06:00

Outpatient Intake Forms

Our Outpatient Treatment Team looks forward to having you in the Palmetto Lowcountry Behavioral Health Outpatient Program. We provide Intensive Outpatient, Partial Hospitalization and C.A.R.E. Substance Use Outpatient Programming based on your needs at the time of your assessment.

Please print off and fill out the forms provided here and bring with you on the day of your assessment.

Psychosocial Self Assessment

Download

Self Report Medical Questionnaire

Download
  • Partnerships
  • Community Resources
  • Outpatient Intake Forms

Palmetto Lowcountry Behavioral Health
2777 Speissegger Drive North Charleston, SC 29405
Phone: 843-747-5830
Toll-free: 877-947-3223

© Palmetto Lowcountry Behavioral Health. All rights reserved.

TRICARE® is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

Physicians are on the medical staff of Palmetto Lowcountry Behavioral Health, but, with limited exceptions, are independent practitioners who are not employees or agents of Palmetto Lowcountry Behavioral Health. The facility shall not be liable for actions or treatments provided by physicians.

Model representations of real patients are shown.

  • HIPAA Notice
  • |
  • Nondiscrimination Notice
  • |
  • Standard Services
  • |
  • Language Assistance
  • |
  • Privacy Policy
  • |
  • Sitemap
  • |
  • Download Adobe Acrobat Reader
  • |
  • No Surprises Act
linkedinfacebook