Child or Adolescent Registration Form - Kevin Willson Counseling

Name of Client

Date

Home Address

City

State/Province

Zip/Postal

Phone Number

Type of Phone

Land Line

Cell Phone

Work Phone

Social Security Number

Date of Birth

Age

Grade Level

School Name

Favorite Activity

Who does the child live with? (Biological parent, foster family, other family member?)

Emergency Contact Name

Relationship to You

Emergency Contact Phone Number

Referred to this office by

Physician's Name

Medications (Type "none" if not taking medication)

Physical Illnesses

Allergies (Type none is child has no allergies)

PARENT INFORMATION

Guardian's / Mother's Name

Social Security Number

Address (If different from above)

City

State/Province

Zip/Postal

Date of Birth

Age

Occupation (Type unemployed if not working)

Home Phone

Work Phone (Type none if not applicable)

Cell Phone (Type none if not applicable)

Employer Name (Type unemployed if not working)

Employer Address

City

State/Province

Zip/Postal

Guardian's / Father's Name

Social Security Number

Address (If different from above)

City

State/Province

Zip/Postal

Date of Birth

Age

Occupation (Type unemployed if not working)

Home Phone

Work Phone (Type none if not applicable)

Cell Phone (Type none if not applicable)

Employer Name (Type unemployed if not working)

Employer Address

City

State/Province

Zip/Postal

Any siblings?

Yes

No

Sibling Name

Date of Birth

Age

Sex

More Siblings?

Add Another Sibling

Sibling Name

Date of Birth

Age

Sex

More Siblings?

Add Another Sibling

Sibling Name

Date of Birth

Age

Sex

More Siblings?

Add Another Sibling

Sibling Name

Date of Birth

Age

Sex

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 of Patient - Child or Adolescent Registration Form

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Today's 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 of Patient

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Today's Date

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5. CHILD OR ADOLESCENT REGISTRATION form

Contact Me TODAY. I'D LOVE TO HEAR FROM YOU.