Main Office
3124 Blue Ridge Road, Suite 102
Raleigh, NC 27612
Office Number: (919) 782‐0021
Brier Creek Office
10208 Cerny Street, Suite 104
Raleigh, NC 27617
Office Number: (919) 226‐0662
*(Please provide legal documentation for any alternative custody arrangements.)
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Please list those living in the child’s home:
If both parents are not living together, who has custody?
Any family members (parents, siblings, grandparents, aunts or uncles only) have these?
Has your child had any problems with or do you have concerns with any of the following:
Thank you for your time filling out this form. Please sign below stating to the best of your knowledge the above information is correct.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I have reviewed the above information with the parent/guardian.
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