New Client Medical History Form

Radiant Recovery and Counseling Services

Pre-Registration Form

We're so excited to begin our partnership with you! To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. If you have any questions, please feel free to contact us at any time. Thank you!

All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *.
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Birth Date*

DayMonthYear
E-mail*
Mobile Phone Number*
Format: 000 000 0000.
How did you hear about us?*
If you were referred, who can we thank for referring you?
Full name please
Emergency Contact*
Name & contact number
PhoneEmailText MessagingOther
Clinic Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Your scheduled session is set aside for you. We do not double book appointments

• Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee 80%. Less than 24 hours notice will incur a cancellation fee of 100% of the scheduled fee

• You will have a consultation with your practitioner to discuss your session
Please sign your initials that you have received and understand our policy:*

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Radiant Recovery and Counseling Services

Pre-Registration Form