Skip to main content
FRAUD ALERT

Be aware of multiple fraudulent text scams requesting payment for NCDMV fees, fines or tolls. NCDMV will NEVER request payment by text. Please report it as spam and delete. Learn More

An official website of the State of North Carolina An official website of NC How you know

State Government websites value user privacy. To learn more, view our full privacy policy.

Secure websites use HTTPS certificates. A lock icon or https:// means you’ve safely connected to the official website.

Utility Menu
  • NCDHHS COVID-19
  • NC.GOV
  • AGENCIES
  • JOBS
Home

Main menu

  • Assistance
    • Assistance
    • ADA and Civil Rights Grievance Procedure
    • Division of Aging
    • Assistive Technology
    • Children's Services
    • Crisis Services
    • Deaf-Blind Services
    • Disability Services
    • Disaster Recovery Health and Safety
    • Guardianship
    • Hearing Loss
    • Low-Income Services
    • Medicaid
    • Mental Health And Substance Use Disorders
    • Mental Health Crisis Services
    • Nondiscrimination and Accessibility Requirements
    • North Carolina Reproductive Health Services
    • Unemployment Services
    • Veteran's Services
    • Vision Loss
    • Vital Records
    • Disaster Preparation
    • Hurricane Dorian Recovery
    • Hurricane Florence Recovery
    • Hurricane Helene Recovery Resources
    • Disaster Preparation and Recovery
  • Divisions
    • Divisions
    • Aging
    • Child and Family Well-Being
    • Child Development And Early Education
    • Disability Determination Services
    • Employment and Independence for People with Disabilities
    • Health Benefits (NC Medicaid)
    • Health Service Regulation
    • Mental Health, Developmental Disabilities and Substance Use Services
    • Office of Economic Opportunity
    • Office of Minority Health and Health Disparities
    • Office of Rural Health
    • Public Health
    • Services for the Blind
    • Services for the Deaf and Hard of Hearing (DSDHH)
    • Social Services
    • State Operated Healthcare Facilities
  • Providers
    • Providers
    • Licensure
    • Provider Information
    • LME-MCO Directory
    • Policies, Manuals and Forms
  • News
    • News
    • Press Releases
    • Media Contacts
    • Events
    • Newsletter Articles
    • Follow NCDHHS on Social Media
  • About
    • About
    • Administrative Offices
    • Data Dashboards, Action Plans/White Papers
    • Department Initiatives
    • DHHS Mission, Vision, Values and Goals
    • Directives
    • Grant Opportunities
    • Leadership
    • Overview
    • Priority Goals
  • Contact
    • Contact
    • Division Contacts
    • Hotlines
    • Report Fraud
    • Vendor Resources

Utility Menu

  • NCDHHS COVID-19
  • NC.GOV
  • AGENCIES
  • JOBS
  1. Home
  2. Providers
  3. Provider Information
  4. Provider Information for Mental Health, Development Disabilities, Substance Use Services and Traumatic Brain Injuries
  5. DWI for Providers

DWI Forms and Clinical Records

Sample Forms

  • 3rd Party Consent Form
  • Client Information Transfer Sheet
  • Client Rights and Grievances
  • Criminal Justice Consent Form
  • Discharge Summary
  • DWI Checklist
  • Individual Consent Form
  • Report of Facility Changes/Additions
  • Service Agreement
  • Service Note
  • Service Note 2
  • Service Note 3
  • Supervision Log I
  • Supervisor Log II
  • Treatment Plan
  • Treatment Providers Consent Form

Related Content

  • DWI for Providers

Side Nav

  • DWI for Providers
    • DWI Forms and Clinical Records
    • DWI Statutes and Rules
    • DWI Statutes

Contact Information

NC Department of Health and Human Services
2001 Mail Service Center
Raleigh, NC 27699-2000

Customer Service Center: 1-800-662-7030
Visit RelayNC for information about TTY services.

Follow Us

Network Menu

  • Employee Directory
  • nc.gov
  • Website Feedback
  • Accessibility
  • Disclaimer & Terms of Use
  • Privacy Policy
  • Open Budget
Hosted on Digital Commons