5. CHILD OR ADOLESCENT REGISTRATION form 5. Child or Adolescent Registration Name of Client * Date * Home Address * Home Address Home Address Home 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 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) Address (If different from above) Address (If different from above) Address (If different from above) 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 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 Employer Address Employer Address Employer 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 Guardian's / Father's Name * Social Security Number * Address (If different from above) Address (If different from above) Address (If different from above) Address (If different from above) 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 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 Employer Address Employer Address Employer 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 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 * Clear 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 * Clear Today's 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