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Minor Registration Form
Minor Registration Form
Step 1 of 9 - Your Information
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Your Information
Name
*
First
Middle
Last
Gender
*
Male
Female
Birthdate
*
MM
DD
YYYY
Age
*
Home Phone
*
Mobile Phone
OK to Leave Messages
*
Yes
No
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
*
Student
High School
How were you referred to us?
Emergency Contact
Name
*
First
Last
Relationship to Client
*
Phone
*
Work Phone
Cell Phone
Occupation
Mother's Information
Type
*
Biological
Step
Foster
Adoptive
Mother's Name
First
Last
Mother's Marital Status
Select one
Single
Married
Divorced
Separated
Living with partner
Widowed
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Mother's Occupation
Mother's Highest Level of Education
Select One
Student
High School
Associates
Bachelors
Masters
Doctorate
Medical School
Father's Information
Type
*
Biological
Step
Foster
Adoptive
Father's Name
First
Last
Father's Marital Status
Select one
Single
Married
Divorced
Separated
Living with partner
Widowed
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Father's Occupation
Father's Highest Level of Education
Select One
Student
High School
Associates
Bachelors
Masters
Doctorate
Medical School
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Medical History
Primary Care Physician
*
Primary Care Physician's Phone
Primary Care Physician's Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
When was your last physical?
*
MM
DD
YYYY
Please check any of the conditions you have had in the past. (check all that apply)
Head Injury
Learning Problems
Alcoholism
Substance Abuse
Hepatitis
Chicken Pox
Rheumatic Fever
Thyroid Problems
Cancer
Sinus Problems
Food Intolerance
Asthma
Speech Problems
Anorexia/Bulimia
Tuberculosis
Special Diets
Hypertension
Stroke
Anemia
Kidney Disease
Hypoglycemia
Heart Problems
Neurological Disease
Gastrointestinal Problems
Sexually Transmitted Disease
Please list any operations or hospitalizations for medical, psychiatric, drug or alcohol related problems and their dates.
Do you use any of the following:
Alcohol
Tobacco
Non-prescription Drugs
None
If you checked any of the above then please list the frequency and dosage amount.
Do you take any medications?
*
Yes
No
If you answered "Yes", please list the name of drug(s), dosage(s), how often, and for what reason.
Reasons for Seeking Our Assistance
What has brought you to this office? (check all that apply)
Depression
Moodiness
Illness
Anxiety
Relationship Issues
Family Problems
Traumatic Experience
Children
Grief/loss
Sexual Problems
Anger
Other
If you answered "Other", please explain
Are you currently having suicidal ideations?
*
Frequently
Sometimes
Rarely
Never
Have you ever had thoughts of hurting yourself?
*
Yes
No
If you answered "Yes", in the past 10 years?
Yes
No
Have you ever had thoughts of hurting someone else?
*
Yes
No
If you answered "Yes", in the past 10 years?
Yes
No
If you answered "Yes" to any of the above questions, please provide further detail.
Do you have a history of any of the following: (check all that apply)
Physical Abuse
Emotional Abuse
Sexual Abuse
If you checked any of the above, please indicate the following: What was the incident(s)? Was the incident(s) reported? Where there any legal authorities involved? What was the outcome(s)?
Have you had previous counseling?
*
Yes
No
If you answered "Yes", please state the Counselor's name and where.
Have you had contact with a Psychiatrist for medication or evaluation?
*
Yes
No
If you answered "Yes", please state the Psychiatrist's name and where.
Are you currently involved in the court system?
*
Yes
No
If you answered "Yes", please tell us the issue.
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
*