Client Registration

Staff ID:
Facility Name:
Program Name:
Consumer MRN/ID
Consumer Guide given CCMHP Provider Directory given Client Registration Client Update
Client Registration
Date

Month Day Year
Date
Client's Current Last Name
First Name
Middle Name
Gen (Sr., Jr)
Name Suffix
Identification
Date of Birth

Month Day Year
Date
Social Security Number
Client Index Number (CIN)
Driver's License Number
Driver's License State
Mother's Last Name
Mother's First Name
County of Birth
State of Birth
Country of Birth

Consent For Evaluation and Treatment

Please read the following PDF:
Before signing this form, make sure that all of your questions and concerns have been addressed. Your signature indicates that you understand all of the policies and proce- dures described in Rainbow’s Consent for Evaluation & Treatment informational packet, and that you understand the following:
- All of the policies and procedures described in the informational packet.
- Violation of any of these policies and procedures may result in the termination of ser vices.
- Therapists and supervisors must also adhere to these policies and procedures.
- You are voluntarily consenting to and authorizing Rainbow’s Clinical Services to pro vide psychological services.
Client's Name:
Client's Signature

Clear
Date

Month Day Year
Date
If two clients are seeing the same therapist together, please have the second client sign below.
Client's Name:
Client's Signature

Clear
Date

Month Day Year
Date
Therapist's Name:
Therapists's Signature

Clear
Date

Month Day Year
Date

Consumer MRN/ID
Consumer Name

First Name Last Name
Financial Information (Family ATP/UMDAP)
Income Type:

Self Parent / Spouse Other
Number of Dependents:
Gross Monthly Income (except foster care children):
Asset Allowance (checking, savings, stocks, bonds, etc.):

Checking Savings Other
Asset allowance amount:
Court ordered obligations paid monthly:
Monthly child care (necessary for employment):
Monthly dependent support payments:
Monthly medical expense payments (in excess of 2% of gross income):
Monthly mandated deductions from gross income for retirement plans (not social security):

Insured (if other than self)
Subscriber Name:

First Name Last Name
Subscriber Birth Date

Month Day Year
Date
Subscriber Social Security Number
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please read and "intial" each by checking the box next to it:

I hereby assign any benefits payable by the above to Contra Costa County Health Services. This amount is not to exceed the regular charges for this period of services. I authorize the county to bill on my behalf any and all identified commercial insurance coverage. [For Educational Related Mental Health Services only] I give my permission for private insurance to be billed. This is a necessary step prior to billing other health coverage such as Medi-Cal for reimbursement. The school district will be billed for any charges denied reimbursed by private insurance or Medi-Cal.
Responsible Party / Legal Guardian Signature (*Child and Family Services is the responsible party for children in Foster Care. The social worker must sign here):

Clear
Date

Month Day Year
Date
Signature

Clear
Date

Month Day Year
Date

Identification