Sample: Registration Form

Client: Last name                                          First                                        Middle Initial

Address                                                           City                             State                Zip

Phone(s):

Home:                         Work:                                      Cell:                             Other:

Date of birth:                                                              Gender:

Spouse/partner/parent: Last name               First                                        Middle Initial

(circle one)

Phone(s):

Home:                         Work:                                      Cell:                             Other:

Date of birth:                                                              Gender:

If client is a child, parents are:

O married        O separated     O never married          O divorced*    O committed relationship                                                                                                                                                                                                                                                                                                                                                                                                     

* A copy of the final decree w/custodial responsibilities must be included in your child’s file    ______ parent initials

Are you the sole custodial parent?     O yes              O no

If no, name of the joint custodial parent:

Phone(s) of joint custodial parent:

Home:                         Work:                                      Cell:                             Other:

How did you hear about us?

Payment is expected at time of your appointment.                                       _____ client initials

(cash, check, or money order)

It is the responsibility of the insured to file for reimbursement.                    _____ client initials