5. CHILD OR ADOLESCENT REGISTRATION form

5. Child or Adolescent Registration
Home Address
Home Address
City
State/Province
Zip/Postal
Type of Phone

PARENT INFORMATION

Address (If different from above)
Address (If different from above)
City
State/Province
Zip/Postal
Employer Address
Employer Address
City
State/Province
Zip/Postal
Address (If different from above)
Address (If different from above)
City
State/Province
Zip/Postal
Employer Address
Employer Address
City
State/Province
Zip/Postal
Any siblings?
More Siblings?
More Siblings?
More Siblings?

PAYMENT INFORMATION

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.

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.

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. 

 

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