2. Adult REGISTRATION form 2. Adult Registration Name of Client * Date * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona 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 State/Province Zip/Postal 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 * Clear 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 * Clear Date * reCAPTCHA If you are human, leave this field blank. Submit Δ Contact Me TODAY. I'D LOVE TO HEAR FROM YOU. *I am not currently accepting new clients but can add you to our waiting list. Contact Us Full Name * Phone Number * Email * Reason for Contacting (Select One) * General Question Help With Forms New Client Inquiry (Add Me to Waiting List) Other Reason for Contacting (Select One) Message * reCAPTCHA If you are human, leave this field blank. Submit Δ
