Adult Registration Form

Your Information
Name*
First Middle Last
Gender*
Birthdate*
MM
DD
YYYY
Age*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Mobile Phone
OK to Leave Messages*
- Yes
- No
Email*
Marital Status*
Spouse's or Partner's Name
Religious Preference
Please list all of the persons with whom you live with, their ages and relationship to you.
Please explain any serious medical problems or physical disabilities in your immediate family (parents, siblings, children)?:
How were you referred to us?

Your Information
What is your highest level of education?*
What is your spouse's highest level of education?*
Your Occupation
Employer
Phone
Spouse's or Partner's Occupation
Employer
Phone

Emergency Contact
Name*
First Last
Relationship to Client*
Phone*
Work Phone
Cell Phone
Occupation

Social Security Number*
Employer's Name
Employer's Address
Street Address Address Line 2 City State ZIP Code
Employer's Primary Insurance Company
Group Number
Member ID/Policy Number
Subscriber's Information
Name
First Last
Subscriber's Social Security Number
Subscriber's Birthdate
MM
DD
YYYY
Subscriber's Relationship to Patient
- Self
- Spouse
- Child
- Other
If you answered "Other", please explain

Communication
How may we communicate with you regarding appointment reminders, general questions, etc?
- Phone
- Email
- Text
- Other
Preferred Phone Number
Preferred Mobile Phone Number
Preferred Email
Other Method

Legal
Cancellation Policy

All clients scheduled with Shelley L. Bartel, LSCSW will be required to leave a credit card on file in order to hold a scheduled appointment time. Should you not call at least 24 business hours in advance to cancel or reschedule an appointment then we will automatically bill your account the entire session fee of $110.00. (For example, if your appointment is at 9:30 am on Monday we would need to receive your call by 9:30 am on the Friday before in order to avoid the cancellation fee)

We find this policy necessary in order to accommodate existing scheduled clients and also those on the lengthy waiting list.

This policy also applies to new clients who we call from the cancellation list. If you accept the appointment and do not come for that appointment, your account will be billed $110.00
Assignment and Release

All accounts are the responsibility of the individual client or parent/guardian and payments are to be made at the time of the appointment. This office will assist you in filing insurance, but takes no responsibility for denial of or delay in payment. I authorize the provider to release to my insurance company(ies) and their bona fide agent(s) such information as may be required to adjudicate my claim, I authorize direct payment of medical benefits to the provider and I hereby assign and set over to such provider all of such benefits. I understand that I am financially responsible to the provider for charges not covered by this authorization.
Client Agreement
Click here to see the Client Agreement
- I have read the Client Agreement and accept the terms.
Print Your Name*
Today's Date*

Step 1 of 8 - Your Information

Your Information

Your Information

Emergency Contact

Medical History

Reasons for Seeking Our Assistance

Subscriber's Information

Communication

Legal

Cancellation Policy

Assignment and Release

Client Agreement