2. Adult REGISTRATION form

2. Adult Registration

Name of Client

Date

Address

City

State/Province

Zip/Postal

Phone Number

Type of Phone

Land Line

Cell Phone

Work Phone

Date of Birth

Age

Occupation (Type N/A for Unemployed)

Employer

Marital Status

Married

Single

Name of Spouse

Spouse's Date of Birth

First Name(s) of Children (Leave Blank if N/A)

Age(s) of Children (Leave Blank if N/A)

Emergency Contact Name

Relationship to You

Emergency Contact Phone Number

PAYMENT INFORMATION

I will be personally responsible and privately paying for charges of treatment.

I will be paying for treatment with my insurance. (Please complete insurance information below)

Primary Insurance Company Name

Subscriber Name

Subscriber Date of Birth

Subscriber Number

Employer Group

Co-Payment

Secondary Insurance Company Name (if any)

Subscriber Name

Subscriber Date of Birth

Subscriber Number

Employer Group

Co-Payment

INSURANCE PAYMENT AUTHORIZATION

I hereby direct my insurer to pay directly to KW Counseling Services, LLC and/or my therapist all benefits due them as a result of claims for my treatment. Although covered by insurance, I am aware that I am personally responsible for all charges. A photostatic copy of this authorization will be valid as the original.

Signature 1 - Adult Registration Form

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Date

INSURANCE RELEASE OF INFORMATION AUTHORIZATION

I hereby authorize KW Counseling Services, LLC and/or my therapist to release information concerning my present condition to insurance carrier for the purpose of processing my claims. A photostatic copy of this authorization will be valid as the original.

Signature 2 - Adult Registration Form

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Date

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*I am not currently accepting new clients but can add you to our waiting list.