CCD Registration Form
Primary Client is a Minor
My Therapist/Case Manager is:
*
Please Select
Laura Bass, LPC
Lori Cadwallader, LPC
Alondra DeLira, LMSW
Kyndal DeBruin, Case Manager
Rebekah dePeo-Christner, LPC
Jacob Doering, LPC Associate
Shaharzade Ebrahimi, LMSW
Marcos Gonzalez, LPC
Andrew Hunter, LPC
Sadaf Meckfessel, LPC
Cindy Jacobson, LPC
"Jake" Jacobson LCSW
Michelle Moore, LPC
Rebecca Torres-West, LPC
Myriam Teller, LPC Associate
Tina Taylor, LPC
Brittany Zielinski, LPC
I don't know/None of the above
DATE OF 1ST SESSION
*
-
Month
-
Day
Year
Date
Information about the Youth
YOUTH LAST NAME
*
FIRST NAME
*
MIDDLE NAME
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
CURRENT OCCUPATION OR "STUDENT"
*
EMPLOYER OR NAME OF SCHOOL
*
INFORMATION ABOUT THE PARENT/GUARDIAN
PARENT NAME
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
PARENT HOME ADDRESS
*
Please provide a physical address, NOT an email
CITY
*
COUNTY
*
STATE
*
ZIP
*
PHONE
*
EMAIL:
*
example@example.com
IN CASE OF EMERGENCY CONTACT INFORMATION
Please choose someone who will NOT be participating in counseling
NAME
*
RELATIONSHIP TO CLIENT
*
PHONE (1)
*
PLEASE LIST ANY CURRENT MEDICATIONS OR MEDICAL CONDITIONS:
PLEASE BRIEFLY DESCRIBE THE REASON YOU ARE SEEKING COUNSELING:
*
WHO REFERRED YOU TO US?
NAME:
*
AGENCY:
*
CLIENT OR PARENT GUARDIAN SIGNATURE
*
Clear
DATE
*
/
Month
/
Day
Year
Date
Are there additional participants OR another parent/guardian?
Yes
No
ADDITIONAL COUNSELING PARTICIPANTS OR AUTHORIZING ADULTS
CLIENT #3 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #4?
Yes
CLIENT #4 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION/STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #5?
Yes
CLIENT #5 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #6?
Yes
CLIENT #6 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Submit
Should be Empty: