Charles K. Burnett, Ph.D., Dr.P.H.                                     105 S. 4th St.
                                                                                                                                                                                                                       Mebane, NC 27302
                                                                                                                                                                                                                         (919) 563-2140

Licensed Psychologist

New Patient Forms

Click here to download the Patient Demographics Form.

Click here to download the New Patient Questionnaire.

Click here to download a Release of Information Form.

Click here to dowload the Patient Contract Form.

Click here to dowload the HIPAA Privacy Notice.