Minor Registration Form

Your Information
Name*
First Middle Last
Gender*
Birthdate*
MM
DD
YYYY
Age*
Home Phone*
Mobile Phone
OK to Leave Messages*
- Yes
- No
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Please list all of the persons with whom you live with, their ages and relationship to you.
What is your highest level of education?*
How were you referred to us?

Mother's Information
Type*
Mother's Name
First Last
Mother's Marital Status
Mother's Phone
Mother's Cell Phone
Mother's Email
Mother's Address (if different from the client's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Occupation
Mother's Highest Level of Education

Father's Information
Type*
Father's Name
First Last
Father's Marital Status
Father's Phone
Father's Cell Phone
Father's Email
Father's Address (if different from the client's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father's Occupation
Father's Highest Level of Education

Insurance Information
Who is responsible for paying your bills?
Social Security Number*
Birthdate (if different from the one on 1st page)
MM
DD
YYYY
Phone (if different from the one on 1st page)
Address (if different from the one on 1st page)
Street Address Address Line 2 City State ZIP Code
Is the person a patient here?
- Yes
- No
Occupation
Employer Insurance Information
Company's Name
Company's Phone
Company's Address
Street Address Address Line 2 City State ZIP Code
Company'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
Client's Relationship to Subscriber
- 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
Preferred Other

Legal
Client Agreement
Click here to see the Client Agreement
Minor Consent Form
This is to certify that I/we (please put your name below), have legal custody or guardianship of my child or children.
Please list your child's or childrens' name(s) and their date of birth.
- I have read the Client Agreement and accept the terms.
- I/We give consent for him/her/them to receive individual and/or family therapy.
Print the name of the Legal Custodial Parent/Guardian*
Print the name of the Legal Custodial Parent/Guardian*
Today's Date*

Your Information