Client Intake

Your information is kept confidential and is only used by PGIC staff to prepare for your care.

About you

Full nameDate of birthEmailPhone

Home address

Emergency contact (name & phone)Payment / insurance

What brings you to PGIC?

Alcohol Marijuana Stimulants Cocaine Benzodiazepines Trauma & PTSD Depression Anxiety Other

Substances used, how often, and when last used

Previous treatment or counseling

Current medications

What would you like to get out of treatment?

I confirm this information is accurate and I agree that PGIC may contact me about my care.

PGIC, Inc.

Our mission is to promote healing and wellness for the suffering addict, their families, and others struggling with psychological and emotional challenges.

2109 St Andrew St #16, Tarboro, NC 27886

Mon - Fri: 8 am - 5 pm · Sat: TBA · Sun: Closed

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