Patient Forms

Please complete the appropriate forms below before your first appointment. If you’re unsure which forms apply to you, feel free to contact our team.

General Patient Forms

Patient Information Form

Disclosure/Release Form

Patient Consent Form

DWI

Patient Information Form

Disclosure/Release Form

Patient Consent Form

RESTORATION FAMILY SERVICES, Inc.

– Office Locations –
714 Wilkins Street – Smithfield, NC 27577
214 Broadway St Suite 7 – Durham, NC 27701
401 S Market St – Benson, NC 27504

Phone: (919) 938 9502
Fax: (919) 938 9702

Email: admin@restorethefamily.org
www.restorethefamily.org

CARF 3 year accreditation for Behavioral Health: Community Integration Respite Services, Alcohol & Drug Addictions, Mental Health Services & DWI Services