Forms, Fees, and Policies

New Client Forms

Click on the link below to access New Client Forms. Please print, complete, and bring them with you to your first meeting. Both the CCC Intake forms and CCC Tele-Health forms are required for Tele-Health clients.

If you are completing these forms digitally, please send the completed forms directly to: covenantkpt@gmail.com

Note that all forms must be downloaded before entering any information or the information will not be saved.

If you are unable to submit these forms digitally, you may fax them to 423-247-1117

Alternatively, you can mail your completed forms to:

PO Box 1323

Kingsport, TN

United States

*Please note, intake forms are taken at your first appointment and are not an application for service. If you have not yet scheduled an appointment, please call our office at 423-247-4536 ext. 2, thank you!

 

Current Sliding Fee Schedule

Fee                           Household Income

$35                          $35,000 and below

$50                             $35,001–$50,000

$65                             $50,001–$65,000

$80                             $65,001–$80,000

$100                         $81,001–$100,000

$125                            $100,000 and up


  • Clients unable to pay the minimum fee will still be seen and fees will be adjusted based upon the individual or family situation.

  • For members of certain Covenant Partner Organizations (which provide financial and other support to the Center), special fee arrangements are in place.  As an example, members of First Baptist Church Kingsport receive one (1) initial session provided at no charge, a $25 charge for the following two sessions, then pay regular sliding scale fees for subsequent sessions.  Several counselors do participate with insurance carriers.

  • Fee payments (or co-pays / deductibles) are due at the time of service.

  • There is a $25.00 fee for late cancellations (less than 24 hour notice) and for “no-shows” EXCEPT in case of valid emergency.

 

Phone: (423) 247-4536 ext. 2

Fax: (423) 247-1117

441 Clay St. #2, Kingsport, TN 37660, USA
Mailing Address: P.O. Box 1323, Kingsport, TN 37662

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